Provider Demographics
NPI:1508494600
Name:JACKSON, COURTNEY ELYSE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELYSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:KIRKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2508 SCOTTSVILLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4400
Mailing Address - Country:US
Mailing Address - Phone:270-746-6330
Mailing Address - Fax:270-904-6337
Practice Address - Street 1:2508 SCOTTSVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4400
Practice Address - Country:US
Practice Address - Phone:270-746-6330
Practice Address - Fax:270-904-6337
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily