Provider Demographics
NPI:1497206783
Name:PEGRAM, JACQUELYN LINDA (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LINDA
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:LINDA
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:3581 HARRODSBURG RD STE 125
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1140
Practice Address - Country:US
Practice Address - Phone:859-313-6200
Practice Address - Fax:859-447-8936
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily