Provider Demographics
NPI:1033165394
Name:BRACKETT, JERRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1514
Mailing Address - Country:US
Mailing Address - Phone:859-582-9331
Mailing Address - Fax:606-789-5600
Practice Address - Street 1:607 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1514
Practice Address - Country:US
Practice Address - Phone:859-582-9331
Practice Address - Fax:606-789-5600
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14390208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000059655OtherANTHEM
KY64143902Medicaid
KY611139169OtherHUMANA
KY340002395OtherRAILROAD MEDICARE
KY611139169OtherHUMANA
KY64143902Medicaid