Provider Demographics
NPI:1841739125
Name:JERVIS, CALLIE JO (FNP-C/APRN)
Entity Type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:JO
Last Name:JERVIS
Suffix:
Gender:F
Credentials:FNP-C/APRN
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:JO
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:255 CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3476
Practice Address - Country:US
Practice Address - Phone:606-260-8613
Practice Address - Fax:859-977-2683
Is Sole Proprietor?:No
Enumeration Date:2017-02-19
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174414363LF0000X
KY3010945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
297980OtherSIHO
KY7100478510Medicaid
000001485530OtherANTHEM
CS2115300253OtherCARESOURCE
KYPDZ000000028490OtherAETNA BETTER HEALTH