Provider Demographics
NPI:1114941895
Name:SUDDUTH, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE B-160
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-276-4486
Practice Address - Fax:859-277-9164
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA687363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000271731OtherBLUE CROSS & BLUE SHIELD
KYP00004815OtherRAILROAD MEDICARE
KY000000271731OtherBLUE CROSS & BLUE SHIELD
KYP00004815OtherRAILROAD MEDICARE