Basic Information
| Provider Information | |||||||||
| NPI: | 1073671673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAENICKE | ||||||||
| FirstName: | KURT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370245009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152211400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 412 N LOCK AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412301115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066384595 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | 31309 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207V00000X | 31309 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 16950 | WV | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | 16950 | WV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0163719 | 05 | OH | MEDICAID | 000000583794 | 01 | KY | ANTHEM BCBS | OTHER | 64313091 | 05 | KY | MEDICAID | 000000510048 | 01 | KY | ANTHEM BCBS | OTHER |