Provider Demographics
NPI:1467653550
Name:GUETIG, JACQUELINE M (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:GUETIG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:RAY
Other - Last Name:MANION
Other - Suffix:
Other - Last Name Type:Other 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:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7430 JEFFERSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-6159
Practice Address - Country:US
Practice Address - Phone:502-969-0975
Practice Address - Fax:502-969-0081
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4541P363L00000X
IN71001870C363LX0106X
KY3004541363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY71000857Medicaid
KY71000857Medicaid