Provider Demographics
NPI:1306594916
Name:EVANS, JACK MICHAEL (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MICHAEL
Last Name:EVANS
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E TIVERTON WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1529
Mailing Address - Country:US
Mailing Address - Phone:859-983-1548
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-41236103K00000X
KY276596103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst