Provider Demographics
NPI:1003122201
Name:HARVEY, JACOB WILLIAM JR (FNP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:HARVEY
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3934 DIXIE HWY
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4163
Mailing Address - Country:US
Mailing Address - Phone:502-377-1406
Mailing Address - Fax:
Practice Address - Street 1:3934 DIXIE HWY
Practice Address - Street 2:SUITE 410
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4163
Practice Address - Country:US
Practice Address - Phone:502-377-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6597363LF0000X
KY3006597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK027710OtherMEDICARE- NICC
KY7100136720Medicaid