1285729368 NPI number — JACKELYN N. BLUES P.A.-C.

Table of content: JACKELYN N. BLUES P.A.-C. (NPI 1285729368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285729368 NPI number — JACKELYN N. BLUES P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUES
Provider First Name:
JACKELYN
Provider Middle Name:
N.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285729368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 NICHOLASVILLE RD
Provider Second Line Business Mailing Address:
SUITE 603
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40503-1471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-277-2211
Provider Business Mailing Address Fax Number:
859-277-7575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 NICHOLASVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 603
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-1471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-277-2211
Provider Business Practice Location Address Fax Number:
859-277-7575
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA247 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA247 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 95002473 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 970020899 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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