Provider Demographics
NPI:1891860599
Name:CONLEY, JODI A (PA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:A
Last Name:CONLEY
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:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:100 BELLEFONTE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1820
Practice Address - Country:US
Practice Address - Phone:606-474-0669
Practice Address - Fax:606-474-0376
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1071595OtherBRICKSTREET/WV COMP
KY7100055310Medicaid
KYS39077Medicare UPIN
KY7100055310Medicaid
WV1071595OtherBRICKSTREET/WV COMP