1336427137 NPI number — MRS. JACLYN LYNAE PETERS

Table of content: MRS. JACLYN LYNAE PETERS (NPI 1336427137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336427137 NPI number — MRS. JACLYN LYNAE PETERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
JACLYN
Provider Middle Name:
LYNAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROSS
Provider Other First Name:
JACLYN
Provider Other Middle Name:
LYNAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336427137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 HENRY CLAY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40502-1024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-268-4545
Provider Business Mailing Address Fax Number:
859-269-1857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 HENRY CLAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40502-1024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-268-4545
Provider Business Practice Location Address Fax Number:
859-269-1857
Provider Enumeration Date:
07/27/2011

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: 235Z00000X , with the licence number:  4095 , 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: 7100334640 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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