Healthcare Provider Details

I. General information

NPI: 1679948491
Provider Name (Legal Business Name): HEATHER LEANN JACKSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 01/09/2024
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SIMMONS ELEMENTARY HEALTHY KIDS CLINIC 830 TYRONE PIKE
VERSAILLES KY
40383-1323
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number283493
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number169029
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: