Provider Demographics
NPI:1750761987
Name:MCLEOD, JENNIFER DENISE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:MCLEOD
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-587-4404
Mailing Address - Fax:502-587-4156
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1886
Practice Address - Country:US
Practice Address - Phone:502-315-1458
Practice Address - Fax:502-479-1425
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009362367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201323230A (KOHMG)Medicaid
KY7100370710 (KOHMG)Medicaid
KYP01535701 RR (KOHMG)Medicare PIN
KYK161790 (KOHMG)Medicare PIN