Provider Demographics
NPI:1609564566
Name:FACKLER, JASON KEITH (ARNP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KEITH
Last Name:FACKLER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-367-4500
Mailing Address - Fax:
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY STE 1105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-367-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026036207RC0000X
KY3019095363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease