Provider Demographics
NPI:1932375391
Name:EVERNHAM, JENELLE K (PA)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:K
Last Name:EVERNHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:K
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:2211 MAYFAIR DR STE 101
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4569
Practice Address - Country:US
Practice Address - Phone:270-688-1352
Practice Address - Fax:270-683-4313
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001008A363A00000X
KYPA1009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100710Medicaid
IN300004679Medicaid
KY33977468Medicare PIN