Provider Demographics
NPI:1548579170
Name:CARR, JESSICA JUNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JUNE
Last Name:CARR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JUNE
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-7653
Mailing Address - Fax:270-575-8359
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-575-3113
Practice Address - Fax:270-575-3135
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1602363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100160260Medicaid
KYK078581Medicare PIN
KY000000685811OtherANTHEM