=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114730025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN KOOGLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2353 AMBRATO WAY
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-866-1909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2353 AMBRATO WAY
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-866-1909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-25-78850
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------