Healthcare Provider Details

I. General information

NPI: 1487210399
Provider Name (Legal Business Name): ANTHONY N. JACKSON MA, LPCC, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK JACKSON MA, LPCC, LCADC

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6445 EAST HAVEN WAY
ALVATON KY
42122
US

IV. Provider business mailing address

1143 FAIRWAY ST STE 103
BOWLING GREEN KY
42103-2452
US

V. Phone/Fax

Practice location:
  • Phone: 502-509-6116
  • Fax:
Mailing address:
  • Phone: 407-347-4536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number297949
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number280595
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: