Provider Demographics
NPI:1063813871
Name:BOCKELMAN, JEREMY (APRN)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BOCKELMAN
Suffix:
Gender:M
Credentials:APRN
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 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:8033 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1344
Practice Address - Country:US
Practice Address - Phone:502-937-3155
Practice Address - Fax:502-935-0743
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100330320Medicaid
KY000000893307OtherANTHEM-NMA
KY165891OtherSIHO-NMA
KY50076921OtherPASSPORT-NMA
KY000000893307OtherANTHEM-NMA