1649812876 NPI number — JENNY BARDENA DURHAM LPCA

Table of content: JENNY BARDENA DURHAM LPCA (NPI 1649812876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649812876 NPI number — JENNY BARDENA DURHAM LPCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURHAM
Provider First Name:
JENNY
Provider Middle Name:
BARDENA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCA
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:
1649812876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST BERNSTADT
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40729-0303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-312-2437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 KY-192
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-657-5470
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2019

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: 101YA0400X , with the licence number:  246663 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 268211 , 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)





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