Provider Demographics
NPI:1225846058
Name:KALK, JACIE R (APSS, TCM, CSA)
Entity type:Individual
Prefix:MISS
First Name:JACIE
Middle Name:R
Last Name:KALK
Suffix:
Gender:F
Credentials:APSS, TCM, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 PORTLAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212
Mailing Address - Country:US
Mailing Address - Phone:502-501-3788
Mailing Address - Fax:502-999-9910
Practice Address - Street 1:2512 PORTLAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212
Practice Address - Country:US
Practice Address - Phone:502-501-3788
Practice Address - Fax:502-999-9910
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist