Provider Demographics
NPI:1083872774
Name:KAVANAUGH, JESSICA L (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:COLYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2050 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1405
Mailing Address - Country:US
Mailing Address - Phone:859-257-4888
Mailing Address - Fax:859-323-1123
Practice Address - Street 1:2050 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1405
Practice Address - Country:US
Practice Address - Phone:859-257-4888
Practice Address - Fax:859-323-1123
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-094893208100000X
KY48980208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002790Medicaid
OH3040999Medicaid
KY7100116160Medicaid
KY7100116160Medicaid