Basic Information
| Provider Information | |||||||||
| NPI: | 1043526064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIPSEY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | R. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 766351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S FLOYD ST STE 700 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026297181 | ||||||||
| FaxNumber: | 5026296957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 28178246A | IN | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 363L00000X | 3006899 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163WD0400X | 1083742 | KY | N | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 000000772805 | 01 | KY | ANTHEM-NMFM | OTHER | 137155 | 01 | KY | SIHO - NMFM | OTHER | 50040392 | 01 | KY | PASSPORT - NMFM | OTHER | 201009490 | 05 | IN | MEDICAID | 7100205410 | 05 | KY | MEDICAID |