Provider Demographics
NPI:1700164373
Name:SOLOMON, JACQUELYN E (LPP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:E
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:LILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8709 LONGBOROUGH WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1132
Mailing Address - Country:US
Mailing Address - Phone:502-428-1728
Mailing Address - Fax:
Practice Address - Street 1:2210 GOLDSMITH LN STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-428-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid