Provider Demographics
NPI:1922008911
Name:PITMAN, JEFFERY BLAKE (DC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:BLAKE
Last Name:PITMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1549
Mailing Address - Country:US
Mailing Address - Phone:270-527-5898
Mailing Address - Fax:270-527-5898
Practice Address - Street 1:1201 BIRCH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1549
Practice Address - Country:US
Practice Address - Phone:270-527-5898
Practice Address - Fax:270-527-5898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4172111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000050197OtherANTHEM
KY85002517Medicaid
KY607460OtherACN
KY85002517Medicaid
KYU36614Medicare UPIN