Provider Demographics
NPI:1598386914
Name:WISLOCKI, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WISLOCKI
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 1:14309 WILLOW GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5158
Mailing Address - Country:US
Mailing Address - Phone:502-550-6767
Mailing Address - Fax:
Practice Address - Street 1:12501 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1530
Practice Address - Country:US
Practice Address - Phone:502-244-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT00355160183700000X
KY30126456183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician