Healthcare Provider Details

I. General information

NPI: 1073671673
Provider Name (Legal Business Name): KURT JAENICKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N LOCK AVE
LOUISA KY
41230-1115
US

IV. Provider business mailing address

PO BOX 5009
BRENTWOOD TN
37024-5009
US

V. Phone/Fax

Practice location:
  • Phone: 606-638-4595
  • Fax:
Mailing address:
  • Phone: 615-221-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number31309
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number31309
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number16950
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number16950
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: