Provider Demographics
NPI:1003212242
Name:NETTLES, JENNIFER SUE (RDH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:NETTLES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-1955
Mailing Address - Country:US
Mailing Address - Phone:270-444-9625
Mailing Address - Fax:270-575-5458
Practice Address - Street 1:916 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-1955
Practice Address - Country:US
Practice Address - Phone:270-444-9625
Practice Address - Fax:270-575-5458
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4144124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist