Provider Demographics
NPI:1376306019
Name:CONKLE, HENRY JACKSON
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:JACKSON
Last Name:CONKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:726-202-3039
Mailing Address - Fax:
Practice Address - Street 1:1111 W 34TH ST STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1916
Practice Address - Country:US
Practice Address - Phone:512-900-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist