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General NPI Number Information
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NPI Number | 1487210399
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Entity Type | Individual
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Provider Name | ANTHONY N. JACKSON MA, LPCC, LCADC
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Gender | Male
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Dates
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Enumeration Date | 05/15/2019
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Last Update Date | 10/30/2025
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Provider Practice Location Address
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Address Line | 6445 EAST HAVEN WAY
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City | ALVATON
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State | KY
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Zip | 42122
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Country | US
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Telephone | 502-509-6116
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Fax |
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Provider Business Mailing Address
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Address Line | 1143 FAIRWAY ST STE 103
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City | BOWLING GREEN
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State | KY
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Zip | 42103-2452
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Country | US
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Telephone | 407-347-4536
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 297949
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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 | 280595
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License Number State | KY
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