Provider Demographics
NPI:1811423460
Name:TESLOW RICKERTSEN, JILLIAN ALLISON (DPM)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALLISON
Last Name:TESLOW RICKERTSEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 US 31W BYP STE 202
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1703
Mailing Address - Country:US
Mailing Address - Phone:270-796-6160
Mailing Address - Fax:270-904-5774
Practice Address - Street 1:734 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3687
Practice Address - Country:US
Practice Address - Phone:502-804-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY263056213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program