Basic Information
| Provider Information | |||||||||
| NPI: | 1568436251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAEGERS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 RIVER HILL RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402071191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028961919 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4121 DUTCHMANS LN | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028979881 | ||||||||
| FaxNumber: | 5028979824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13244 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 13244 | 01 | KY | MEDICAL LICENSE | OTHER | 6413244200 | 05 | KY | MEDICAID |