Healthcare Provider Details

I. General information

NPI: 1396120820
Provider Name (Legal Business Name): GML PAIN MD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 MAPLE BROOK DR
LOUISVILLE KY
40241-2080
US

IV. Provider business mailing address

11300 MAPLE BROOK DR
LOUISVILLE KY
40241-2080
US

V. Phone/Fax

Practice location:
  • Phone: 502-253-0505
  • Fax: 502-253-0303
Mailing address:
  • Phone: 502-253-0505
  • Fax: 502-253-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEFFERNIKA JACKSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 502-253-0505