Provider Demographics
NPI:1336136365
Name:SHADBURNE, JESSICA D (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:SHADBURNE
Suffix:
Gender:F
Credentials:CRNA
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:3920 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-259-6710
Practice Address - Fax:502-259-6704
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1094943367500000X
KY3003303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCH6488OtherRR MEDICARE GROUP NUMBER
KY1134761OtherPASSPORT
KY74441502Medicaid
IN201208770Medicaid
KY2437849000OtherPASSPORT ADVANTAGE
KY000000245148OtherBLUE SHIELD
KY430063052OtherRAILROAD MEDICARE
KY430063052OtherRAILROAD MEDICARE