Provider Demographics
NPI:1972367076
Name:CAPITAL CITY PSYCH & MENTAL HEALTH
Entity type:Organization
Organization Name:CAPITAL CITY PSYCH & MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-385-0806
Mailing Address - Street 1:2955 SHADRICK FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-9476
Mailing Address - Country:US
Mailing Address - Phone:502-330-8522
Mailing Address - Fax:
Practice Address - Street 1:409 HOLMES ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2209
Practice Address - Country:US
Practice Address - Phone:502-385-0806
Practice Address - Fax:502-385-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty