Healthcare Provider Details

I. General information

NPI: 1336213784
Provider Name (Legal Business Name): JACKSON BEHAVIORAL HEALTH PROFESSIONALS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 MASTER ST
CORBIN KY
40701-1065
US

IV. Provider business mailing address

PO BOX 2343
LONDON KY
40743-2343
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-9500
  • Fax: 606-526-8080
Mailing address:
  • Phone: 606-526-9500
  • Fax: 606-526-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberKY0480
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberKY1625
License Number StateKY

VIII. Authorized Official

Name: MR. WILLIAM MATT ELLISON
Title or Position: PROPRIETOR
Credential: LCSW
Phone: 606-526-9500