Provider Demographics
NPI:1114182326
Name:PEDERSEN, JASEN THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASEN
Middle Name:THOMAS
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 WESTWIND WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-6773
Mailing Address - Country:US
Mailing Address - Phone:502-276-9999
Mailing Address - Fax:502-276-9999
Practice Address - Street 1:6400 WESTWIND WAY
Practice Address - Street 2:SUITE B
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-6773
Practice Address - Country:US
Practice Address - Phone:502-276-9999
Practice Address - Fax:502-276-9999
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY243971213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100170810Medicaid
KY000000866560OtherANTHEM
KYP01347650Medicare PIN
KY000000866560OtherANTHEM
KY50034107OtherPASSPORT