Provider Demographics
NPI:1245402262
Name:DAVIS, JACQUELINE EILEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:EILEEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:EILEEN
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5063
Mailing Address - Fax:
Practice Address - Street 1:3 AUDUBON PLAZA DR STE 430
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-636-4900
Practice Address - Fax:502-636-4901
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100054590Medicaid
KY50022601OtherPASSPORT HEALTH PLAN
KY50022601OtherPASSPORT HEALTH PLAN
KY7100054590Medicaid