Provider Demographics
NPI:1598200602
Name:SUPPORTIVE MED
Entity Type:Organization
Organization Name:SUPPORTIVE MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-324-0334
Mailing Address - Street 1:1224 HOODS CREEK PIKE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7220
Mailing Address - Country:US
Mailing Address - Phone:606-324-0334
Mailing Address - Fax:606-324-0447
Practice Address - Street 1:1224 HOODS CREEK PIKE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7220
Practice Address - Country:US
Practice Address - Phone:606-324-0334
Practice Address - Fax:606-324-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010417 1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care