Provider Demographics
NPI:1699355719
Name:DAMRON, JESSICA LEANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANN
Last Name:DAMRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEANN
Other - Last Name:SOWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2108 SAINT MATHILDA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1128
Mailing Address - Country:US
Mailing Address - Phone:859-693-9942
Mailing Address - Fax:
Practice Address - Street 1:424 LEWIS HARGETT CIR STE B100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3683
Practice Address - Country:US
Practice Address - Phone:859-475-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY269236225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY269236Medicaid