Provider Demographics
NPI:1396183380
Name:YOCOM, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:YOCOM
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 1:2011 LAUDERDALE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1529
Mailing Address - Country:US
Mailing Address - Phone:502-417-5514
Mailing Address - Fax:
Practice Address - Street 1:214 BRECKENRIDGE LN STE 114
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3868
Practice Address - Country:US
Practice Address - Phone:502-653-7211
Practice Address - Fax:502-416-0723
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY710035120Medicaid