Healthcare Provider Details

I. General information

NPI: 1013324136
Provider Name (Legal Business Name): JACOB A BISHOP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 FOUNTAIN CT
LEXINGTON KY
40509-1888
US

IV. Provider business mailing address

5200 COMMERCE CROSSING 3RD FLOOR
LOUISVILLE KY
40229
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6861
  • Fax:
Mailing address:
  • Phone: 502-253-4924
  • Fax: 502-489-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3432
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR3432
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: