Provider Demographics
NPI:1508272246
Name:JEWELL, ELIZABETH (CSA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JEWELL
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 LEMAN DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2524
Mailing Address - Country:US
Mailing Address - Phone:502-292-7676
Mailing Address - Fax:
Practice Address - Street 1:2710 TRUMPETVINE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-5602
Practice Address - Country:US
Practice Address - Phone:502-292-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2021-02-22
Deactivation Date:2014-08-29
Deactivation Code:
Reactivation Date:2019-09-25
Provider Licenses
StateLicense IDTaxonomies
KYSA269247200000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other