Healthcare Provider Details

I. General information

NPI: 1528078367
Provider Name (Legal Business Name): JOHN (JACK) KENNETH BORDERS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 ASHLAND DR
ASHLAND KY
41101-7058
US

IV. Provider business mailing address

2000 ASHLAND DR P.O. BOX 1447
ASHLAND KY
41101-7058
US

V. Phone/Fax

Practice location:
  • Phone: 606-326-0322
  • Fax: 606-326-9809
Mailing address:
  • Phone: 606-326-0322
  • Fax: 606-326-9809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21774
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: