Provider Demographics
NPI:1386094712
Name:JACKSON, JOHNNIE MAC (MSW, CSW)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:MAC
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7160 N MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3151
Mailing Address - Country:US
Mailing Address - Phone:606-657-9988
Mailing Address - Fax:
Practice Address - Street 1:7160 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3151
Practice Address - Country:US
Practice Address - Phone:606-657-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY254558101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health