Provider Demographics
NPI:1790327914
Name:RICHARDS, JESSICA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:RICHARDS
Suffix:
Gender:F
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4714
Practice Address - Country:US
Practice Address - Phone:502-599-3930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1157474363A00000X
KYTC978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant