Provider Demographics
NPI:1700989258
Name:NOLAND, JACKIE C (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:C
Last Name:NOLAND
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 1:6387 US 150 E
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484
Mailing Address - Country:US
Mailing Address - Phone:859-749-0561
Mailing Address - Fax:
Practice Address - Street 1:206 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1456
Practice Address - Country:US
Practice Address - Phone:606-528-0283
Practice Address - Fax:606-528-8422
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4355P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYQ39185Medicare UPIN