Healthcare Provider Details

I. General information

NPI: 1174322382
Provider Name (Legal Business Name): JONATHAN BALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date: 04/28/2026
Reactivation Date: 06/29/2026

III. Provider practice location address

780 ROSE STREET
LEXINGTON KY
40536
US

IV. Provider business mailing address

780 ROSE STREET
LEXINGTON KY
40536
US

V. Phone/Fax

Practice location:
  • Phone: 606-226-3857
  • Fax:
Mailing address:
  • Phone: 606-226-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number99241
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: