Provider Demographics
NPI:1073763801
Name:DAVIS, JACALYN VANNESSA (KCSA)
Entity Type:Individual
Prefix:MISS
First Name:JACALYN
Middle Name:VANNESSA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1629
Mailing Address - Country:US
Mailing Address - Phone:502-377-0628
Mailing Address - Fax:
Practice Address - Street 1:709 E MADISON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1629
Practice Address - Country:US
Practice Address - Phone:502-377-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKSCA176282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital