Provider Demographics
NPI:1144337353
Name:JACKSON, LLOYD DALLAS (LCSW)
Entity type:Individual
Prefix:MR
First Name:LLOYD
Middle Name:DALLAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 BARNES MILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-9747
Mailing Address - Country:US
Mailing Address - Phone:859-684-5669
Mailing Address - Fax:
Practice Address - Street 1:1018 E NEW CIRCLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4145
Practice Address - Country:US
Practice Address - Phone:859-893-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1878101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health