Provider Demographics
NPI:1497267637
Name:ENNIS, JONATHON LEE (PAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:LEE
Last Name:ENNIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:805 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-1513
Mailing Address - Country:US
Mailing Address - Phone:859-481-7113
Mailing Address - Fax:859-481-7114
Practice Address - Street 1:805 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069
Practice Address - Country:US
Practice Address - Phone:859-481-7113
Practice Address - Fax:859-481-7114
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100515140Medicaid