Healthcare Provider Details

I. General information

NPI: 1124825104
Provider Name (Legal Business Name): JAKE CARMER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 LEXINGTON AVE
LEXINGTON KY
40508
US

IV. Provider business mailing address

1809 MEETING ST APT 10230
LEXINGTON KY
40509-4614
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-6490
  • Fax:
Mailing address:
  • Phone: 949-558-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2283
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: