Provider Demographics
NPI:1023135126
Name:JACKSON, KIMBERLY ANN (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
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 37
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-0037
Mailing Address - Country:US
Mailing Address - Phone:270-667-7017
Mailing Address - Fax:270-667-9065
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1261
Practice Address - Country:US
Practice Address - Phone:270-667-7017
Practice Address - Fax:270-667-9065
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1086349363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK185610OtherMEDICARE - RHCA
KY7100128660Medicaid
KY7100128660Medicaid
KY0050404Medicare ID - Type UnspecifiedCALDWELL COUNTY HEALTH D
KY0290905Medicare ID - Type UnspecifiedCRITTENDEN CO HEALTH DEPT
KYP27287Medicare UPIN
KY0291003Medicare ID - Type UnspecifiedLIVINGSTON CO HEALTH DEPT