Healthcare Provider Details

I. General information

NPI: 1679916191
Provider Name (Legal Business Name): MR. JASON AARON COFFEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

IV. Provider business mailing address

509 MEMORIAL DR STE 2
MANCHESTER KY
40962-6196
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-4080
  • Fax: 606-598-1688
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLPCPCC00225353
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: