Provider Demographics
NPI:1356762686
Name:COON, JESSICA LYNNELLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNELLE
Last Name:COON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 WALLER AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2918
Mailing Address - Country:US
Mailing Address - Phone:859-271-9448
Mailing Address - Fax:
Practice Address - Street 1:343 WALLER AVE STE 201
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2918
Practice Address - Country:US
Practice Address - Phone:859-271-9448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid