Provider Demographics
NPI:1033270657
Name:SECREST, JENNIFER ERIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ERIN
Last Name:SECREST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 LINN STATION RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3840
Mailing Address - Country:US
Mailing Address - Phone:502-410-1710
Mailing Address - Fax:
Practice Address - Street 1:200 DON ALLEN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3910
Practice Address - Country:US
Practice Address - Phone:502-727-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010855A1223G0001X
KY83991223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200835020Medicaid