Healthcare Provider Details

I. General information

NPI: 1194207910
Provider Name (Legal Business Name): LJKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WINCHESTER RD STE 147
LEXINGTON KY
40505-4179
US

IV. Provider business mailing address

1301 WINCHESTER RD STE 147
LEXINGTON KY
40505-4179
US

V. Phone/Fax

Practice location:
  • Phone: 859-309-2814
  • Fax: 859-309-1791
Mailing address:
  • Phone: 859-309-2814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JANA JACOBSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 859-552-1272