Provider Demographics
NPI:1336492677
Name:PRAHL, JESSICA BROOKE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:BROOKE
Last Name:PRAHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BROOKE
Other - Last Name:GUSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2309
Mailing Address - Country:US
Mailing Address - Phone:270-706-5515
Mailing Address - Fax:270-706-5516
Practice Address - Street 1:1111 RING RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4900
Practice Address - Country:US
Practice Address - Phone:270-706-5515
Practice Address - Fax:270-706-5516
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100255980Medicaid
KY7100255980Medicaid