=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629075692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB WILLIAM VINCENT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3615 E JOHN ROWAN BLVD STE 104
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-3264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-348-5968
-----------------------------------------------------
Fax | 270-706-5802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3615 E JOHN ROWAN BLVD STE 104
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-3264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-348-5968
-----------------------------------------------------
Fax | 270-706-5802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34239
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------