Provider Demographics
NPI:1962704908
Name:JACKSON PAIN MANAGEMENT CLINIC, PLLC
Entity type:Organization
Organization Name:JACKSON PAIN MANAGEMENT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KNETSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-583-3461
Mailing Address - Street 1:327 BRIARCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-9789
Mailing Address - Country:US
Mailing Address - Phone:859-583-2142
Mailing Address - Fax:859-236-0261
Practice Address - Street 1:327 BRIARCLIFF LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-9789
Practice Address - Country:US
Practice Address - Phone:859-583-2142
Practice Address - Fax:859-236-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain