Healthcare Provider Details

I. General information

NPI: 1801846647
Provider Name (Legal Business Name): JON RUSSELL UREY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 RING RD SUITE 102
ELIZABETHTOWN KY
42701-7945
US

IV. Provider business mailing address

2608 RING RD SUITE 102
ELIZABETHTOWN KY
42701-7945
US

V. Phone/Fax

Practice location:
  • Phone: 270-763-9577
  • Fax: 270-763-6938
Mailing address:
  • Phone: 270-763-9577
  • Fax: 270-763-6938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberKY634
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: