Provider Demographics
NPI:1053509729
Name:KIRBY, JACQUELYN (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:KIRBY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 HOPKINSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1124
Mailing Address - Country:US
Mailing Address - Phone:270-338-5777
Mailing Address - Fax:270-338-5765
Practice Address - Street 1:480 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1124
Practice Address - Country:US
Practice Address - Phone:270-338-5777
Practice Address - Fax:270-338-5765
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5363P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000545943OtherBCBS
611268014OtherFEDERAL TAX ID
KY31000458Medicaid
KY000000545943OtherBCBS
611268014OtherFEDERAL TAX ID