Provider Demographics
NPI:1114049095
Name:JACO, VANESSA LEE (CRNP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LEE
Last Name:JACO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-1701
Mailing Address - Country:US
Mailing Address - Phone:606-573-4520
Mailing Address - Fax:
Practice Address - Street 1:37 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1701
Practice Address - Country:US
Practice Address - Phone:606-573-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-087710363LA2100X
KY4010950363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL112805Medicaid
AL51515966OtherBCBS
AL510-49323OtherBCBS
AL112809Medicaid
AL510-49324OtherBCBS
AL515-98704OtherBCBS
AL051553292Medicaid
AL112804Medicaid
AL112806Medicaid
AL510-49321OtherBCBS
AL510-49322OtherBCBS
AL510-49443OtherBCBS
ALP00015330OtherRAILROAD MEDICARE
AL112813Medicaid
AL112815Medicaid
AL112815Medicaid
AL102I504012Medicare PIN
AL112809Medicaid
AL112806Medicaid
AL051553292Medicaid