Provider Demographics
NPI:1376051318
Name:GAMMON, JORDYN BOCOOK (APRN)
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:BOCOOK
Last Name:GAMMON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:RENEE
Other - Last Name:BOCOOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2000 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-9068
Mailing Address - Country:US
Mailing Address - Phone:606-706-1671
Mailing Address - Fax:
Practice Address - Street 1:230 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422
Practice Address - Country:US
Practice Address - Phone:859-236-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3011996OtherAPRN KENTUCKY LICENSE