Healthcare Provider Details

I. General information

NPI: 1710845151
Provider Name (Legal Business Name): JOHNATHAN LUCAS BENNETT CADCA I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. LUCAS LUCAS BENNETT

II. Dates (important events)

Enumeration Date: 01/14/2026
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 STORY AVE
LOUISVILLE KY
40206-1739
US

IV. Provider business mailing address

1675 STORY AVE
LOUISVILLE KY
40206-1739
US

V. Phone/Fax

Practice location:
  • Phone: 502-749-6344
  • Fax: 502-749-6344
Mailing address:
  • Phone: 502-749-6344
  • Fax: 502-749-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301969
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number4035841
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: