Provider Demographics
NPI:1609564566
Name:FACKLER, JASON KEITH (ARNP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KEITH
Last Name:FACKLER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 BRANDENBURG RD
Mailing Address - Street 2:
Mailing Address - City:EKRON
Mailing Address - State:KY
Mailing Address - Zip Code:40117-8529
Mailing Address - Country:US
Mailing Address - Phone:859-979-0151
Mailing Address - Fax:
Practice Address - Street 1:803 E DIXIE AVE FL 34748
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6013
Practice Address - Country:US
Practice Address - Phone:352-530-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026036207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease