Provider Demographics
NPI:1043432149
Name:FORTNEY, JERELYNN D (MS)
Entity Type:Individual
Prefix:MS
First Name:JERELYNN
Middle Name:D
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 LARKIN ROAD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3256
Mailing Address - Country:US
Mailing Address - Phone:859-278-7171
Mailing Address - Fax:859-278-6503
Practice Address - Street 1:2505 LARKIN ROAD
Practice Address - Street 2:SUITE #104
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3256
Practice Address - Country:US
Practice Address - Phone:859-278-7171
Practice Address - Fax:859-278-6503
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist