Healthcare Provider Details

I. General information

NPI: 1609564566
Provider Name (Legal Business Name): JASON KEITH FACKLER ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 ABRAHAM FLEXNER WAY STE 1105
LOUISVILLE KY
40202-3841
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-4500
  • Fax:
Mailing address:
  • Phone: 502-367-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberAPRN11026036
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3019095
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: