=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194207910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LJKS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2018
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 WINCHESTER RD STE 147
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40505-4179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-309-2814
-----------------------------------------------------
Fax | 859-309-1791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 WINCHESTER RD STE 147
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40505-4179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-309-2814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | JANA JACOBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-552-1272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2084P0015X
-----------------------------------------------------
Taxonomy Name | Psychosomatic Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------