MEDICARE: MR. JOHNATHAN LUCAS BENNETT CADCA I

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	376K00000X	Nurse's Aide	4035841	KY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	301969	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4035841	OTHER	KY	SRNA
2	301969	OTHER	KY	CADCA

General Provider Information

NPI Number	:	1710845151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNATHAN LUCAS BENNETT CADCA I

Provider Business Mailing Address
First Line	:	1675 STORY AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1739
Country	:	US
Telephone Number	:	502-749-6344
Fax Number	:	502-749-6344

Provider Business Practice Location Address
First Line	:	1675 STORY AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1739
Country	:	US
Telephone Number	:	502-749-6344
Fax Number	:	502-749-6344

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

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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