Provider Demographics
NPI:1801837125
Name:ANDERSON, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10216 TAYLORSVILLE RD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3616
Mailing Address - Country:US
Mailing Address - Phone:502-261-2182
Mailing Address - Fax:502-240-6481
Practice Address - Street 1:2020 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1803
Practice Address - Country:US
Practice Address - Phone:502-261-2182
Practice Address - Fax:502-240-6481
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA240363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000915Medicaid
KY970010231Medicare PIN
KY95000915Medicaid
KYR95320Medicare UPIN