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General NPI Number Information
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NPI Number | 1336213784
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Entity Type | Organization
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Legal Business Name | JACKSON BEHAVIORAL HEALTH PROFESSIONALS, PLLC
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Dates
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Enumeration Date | 11/19/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1013 MASTER ST
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City | CORBIN
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State | KY
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Zip | 40701-1065
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Country | US
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Telephone | 606-526-9500
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Fax | 606-526-8080
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Provider Business Mailing Address
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Address Line | PO BOX 2343
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City | LONDON
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State | KY
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Zip | 40743-2343
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Country | US
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Telephone | 606-526-9500
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Fax | 606-526-8080
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Authorized Official
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Title or Position | PROPRIETOR
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Name | MR. WILLIAM MATT ELLISON
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Credential | LCSW
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Telephone | 606-526-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | KY1625
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | KY0480
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License Number State | KY
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