Provider Demographics
NPI:1528078367
Name:BORDERS, JOHN (JACK) KENNETH JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN (JACK)
Middle Name:KENNETH
Last Name:BORDERS
Suffix:JR
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 1:2000 ASHLAND DR
Mailing Address - Street 2:P.O. BOX 1447
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7058
Mailing Address - Country:US
Mailing Address - Phone:606-326-0322
Mailing Address - Fax:606-326-9809
Practice Address - Street 1:2000 ASHLAND DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7058
Practice Address - Country:US
Practice Address - Phone:606-326-0322
Practice Address - Fax:606-326-9809
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY217742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413047Medicaid
KY64764996Medicaid
000000050360OtherANTHEM 12 DIGIT NUMBER
OH0413047Medicaid
KY0296201Medicare ID - Type Unspecified