Provider Demographics
NPI:1023543535
Name:SHOUP, JAIME (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:SHOUP
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2933 BRECKENRIDGE LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1494
Practice Address - Country:US
Practice Address - Phone:502-588-0736
Practice Address - Fax:502-588-0721
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY579232084E0001X, 2084N0402X
IN01093584A2084N0402X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program