Provider Demographics
NPI:1336222512
Name:NELSON, JENNIFER WILES (DO)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:WILES
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2850 LONE OAK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8043
Mailing Address - Country:US
Mailing Address - Phone:270-554-3904
Mailing Address - Fax:270-534-8928
Practice Address - Street 1:2850 LONE OAK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8043
Practice Address - Country:US
Practice Address - Phone:270-554-3904
Practice Address - Fax:270-534-8928
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64068638Medicaid
KY64068638Medicaid
H92055Medicare UPIN