Provider Demographics
NPI:1073705968
Name:RICHARDSON, JERI K (CNS)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:K
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-1411
Mailing Address - Country:US
Mailing Address - Phone:606-564-4016
Mailing Address - Fax:606-564-0295
Practice Address - Street 1:611 FOREST AVE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-1411
Practice Address - Country:US
Practice Address - Phone:606-564-4016
Practice Address - Fax:606-564-0295
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN228692163WP0809X
OHCOA.07413-NS364SP0809X
KY1113513163WP0809X
KY3010172364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNS03463Medicare PIN
OHNS03467Medicare PIN
OHNS03464Medicare PIN
OHNS03466Medicare PIN
OHNS03465Medicare PIN