Provider Demographics
NPI:1982360715
Name:JERNIGAN, MADISON (MS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 STONE CREEK PKWY STE 7
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5366
Mailing Address - Country:US
Mailing Address - Phone:502-915-8343
Mailing Address - Fax:
Practice Address - Street 1:800 STONE CREEK PKWY STE 7
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5366
Practice Address - Country:US
Practice Address - Phone:502-915-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY273878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty