Provider Demographics
NPI:1497167472
Name:BOOTH, JENNIFER A (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BOOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:AGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1501 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1054
Mailing Address - Country:US
Mailing Address - Phone:270-686-7747
Mailing Address - Fax:270-926-9862
Practice Address - Street 1:1600 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1055
Practice Address - Country:US
Practice Address - Phone:270-686-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008566363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1497167472Medicaid
IN201230250Medicaid