MEDICARE: JENNIFER THACKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	R1290	KY

General Provider Information

NPI Number	:	1306277496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER THACKER

Provider Business Mailing Address
First Line	:	3507 STONY BROOK DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-1541
Country	:	US
Telephone Number	:	502-494-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 BROWNS LN
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-1523
Country	:	US
Telephone Number	:	502-459-8900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2013
Last Update Date	:	11/27/2013

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Directions to “ JENNIFER THACKER ” Practice Location

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