Healthcare Provider Details

I. General information

NPI: 1114312220
Provider Name (Legal Business Name): JENNIFER VAN LUNTEREN WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST UNIT 610
LOUISVILLE KY
40202-5711
US

IV. Provider business mailing address

401 E CHESTNUT ST UNIT 600
LOUISVILLE KY
40202-5705
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4450
  • Fax: 502-588-9539
Mailing address:
  • Phone: 502-588-4425
  • Fax: 502-588-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52761
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: