Healthcare Provider Details

I. General information

NPI: 1649226549
Provider Name (Legal Business Name): CALVIN JACKSON LPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N DIXIE HWY
ELIZABETHTOWN KY
42701-2621
US

IV. Provider business mailing address

107 CRANES ROOST CT
ELIZABETHTOWN KY
42701-3650
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-1304
  • Fax: 270-234-8028
Mailing address:
  • Phone: 270-765-2605
  • Fax: 270-766-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0274
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: