Provider Demographics
NPI:1629075692
Name:VINCENT, JACOB WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 E JOHN ROWAN BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-3264
Mailing Address - Country:US
Mailing Address - Phone:502-348-5968
Mailing Address - Fax:270-706-5802
Practice Address - Street 1:3615 E JOHN ROWAN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-3264
Practice Address - Country:US
Practice Address - Phone:502-348-5968
Practice Address - Fax:270-706-5802
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64014111Medicaid