Provider Demographics
NPI:1497042113
Name:GARDNER, JESSICA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:ALBANESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:425 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3409
Mailing Address - Country:US
Mailing Address - Phone:859-341-3575
Mailing Address - Fax:859-341-5701
Practice Address - Street 1:425 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3409
Practice Address - Country:US
Practice Address - Phone:859-341-3575
Practice Address - Fax:859-341-5701
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1098672OtherNCCPA
K010380Medicare PIN