Provider Demographics
NPI:1437221520
Name:PATTERSON, JACK K (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:K
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:KELLY
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:208 S MAIN
Mailing Address - Street 2:PO 385
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134
Mailing Address - Country:US
Mailing Address - Phone:270-813-2520
Mailing Address - Fax:270-713-0234
Practice Address - Street 1:208 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134
Practice Address - Country:US
Practice Address - Phone:270-813-2520
Practice Address - Fax:270-713-0234
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64272131Medicaid
KY65929200Medicaid
KY000000049404OtherANTHEM BC
KY000000305382OtherANTHEM BC PHYSICAL THERAP
61-1175802OtherTAX ID
KY65929200Medicaid
0397401Medicare PIN