Provider Demographics
NPI:1265046247
Name:JERNIGAN, WILLIAM III (LMT)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:JERNIGAN
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 TERRY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1732
Mailing Address - Country:US
Mailing Address - Phone:502-314-9276
Mailing Address - Fax:
Practice Address - Street 1:1860 MELLWOOD AVE STE 179
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1033
Practice Address - Country:US
Practice Address - Phone:502-365-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY260894225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist