Provider Demographics
NPI:1861640104
Name:STREET, JENNIFER RUTH (MS, PA-C, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RUTH
Last Name:STREET
Suffix:
Gender:F
Credentials:MS, PA-C, ATC
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-587-8222
Practice Address - Fax:502-587-0160
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2311363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100491200Medicaid
IN300047016Medicaid