Provider Demographics
NPI:1104439355
Name:AMYX, JASON (LPCC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:AMYX
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7360
Mailing Address - Country:US
Mailing Address - Phone:270-559-8247
Mailing Address - Fax:
Practice Address - Street 1:78 CAKY DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7592
Practice Address - Country:US
Practice Address - Phone:270-527-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-27
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245735101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY245735OtherPROFESSIONAL LICENSE