Healthcare Provider Details

I. General information

NPI: 1619073202
Provider Name (Legal Business Name): GREGORY ALEXANDER JICHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE J 401
LEXINGTON KY
40536-0284
US

IV. Provider business mailing address

740 S LIMESTONE J 401
LEXINGTON KY
40536-0284
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5661
  • Fax: 859-257-4999
Mailing address:
  • Phone: 859-323-5661
  • Fax: 859-257-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number39627
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: