Provider Demographics
NPI:1952691057
Name:JLS MEDICAL ENTERPRISES PSC
Entity Type:Organization
Organization Name:JLS MEDICAL ENTERPRISES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:SANTIESTEBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-1162
Mailing Address - Street 1:400 UNIVERSITY DR
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1080
Mailing Address - Country:US
Mailing Address - Phone:606-886-4277
Mailing Address - Fax:
Practice Address - Street 1:400 UNIVERSITY DR
Practice Address - Street 2:SUITE 201B
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1080
Practice Address - Country:US
Practice Address - Phone:606-886-4277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100175380Medicaid