Healthcare Provider Details

I. General information

NPI: 1639705619
Provider Name (Legal Business Name): CHRISTIAN JACOB PEMBERTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2020
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 GRAND AVE
NEWPORT KY
41071-2570
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-5901
  • Fax: 859-301-5940
Mailing address:
  • Phone: 859-301-5901
  • Fax: 859-301-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number58963
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: