=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104439355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON AMYX LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2020
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 858 5TH AVE SE
-----------------------------------------------------
City | CALVERT CITY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-559-8247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 956 FAIRVIEW ST
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42025-7360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-559-8247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 245735
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------