1376051318 NPI number — JORDYN BOCOOK GAMMON APRN

Table of content: JORDYN BOCOOK GAMMON APRN (NPI 1376051318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376051318 NPI number — JORDYN BOCOOK GAMMON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMMON
Provider First Name:
JORDYN
Provider Middle Name:
BOCOOK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOCOOK
Provider Other First Name:
JORDYN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376051318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 WEBSTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40422-9068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-706-1671
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 W MAIN ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-236-9670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2018

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: 363LF0000X , with the licence number:  3011996 , 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)