Provider Demographics
NPI:1225524812
Name:JARVIS, JON R (APRN)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:JARVIS
Suffix:
Gender:M
Credentials:APRN
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 579
Mailing Address - Street 2:
Mailing Address - City:MUNFORDVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42765-0579
Mailing Address - Country:US
Mailing Address - Phone:270-524-7231
Mailing Address - Fax:270-524-7415
Practice Address - Street 1:117 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765-9084
Practice Address - Country:US
Practice Address - Phone:270-524-7231
Practice Address - Fax:270-524-7415
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14281793OtherCAQH
KY7100552300Medicaid