Provider Demographics
NPI:1609560911
Name:CLEVINGER, JERRY WESLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WESLEY
Last Name:CLEVINGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 CHAMBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-4220
Mailing Address - Country:US
Mailing Address - Phone:502-699-2285
Mailing Address - Fax:
Practice Address - Street 1:617 CHAMBERLIN AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4220
Practice Address - Country:US
Practice Address - Phone:502-699-2285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYPA3210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program