Provider Demographics
NPI:1255309506
Name:GARGUS, JESSICA LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GARGUS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:270-326-3949
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1210 JOHNSON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2973
Practice Address - Country:US
Practice Address - Phone:270-759-4098
Practice Address - Fax:270-761-4131
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004694363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78016318Medicaid
KYQ53196Medicare UPIN
KYK076191Medicare PIN
KY78016318Medicaid
KY78016318Medicaid