Provider Demographics
NPI:1699211631
Name:VAN WATERS, JACQUELYN E (NP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:E
Last Name:VAN WATERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 MINTER RD
Mailing Address - Street 2:
Mailing Address - City:SYMSONIA
Mailing Address - State:KY
Mailing Address - Zip Code:42082-9402
Mailing Address - Country:US
Mailing Address - Phone:270-703-9095
Mailing Address - Fax:
Practice Address - Street 1:2670 NEW HOLT RD STE C
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7506
Practice Address - Country:US
Practice Address - Phone:270-575-1010
Practice Address - Fax:270-575-1007
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011205363L00000X
KYUNKNOWN363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily