Basic Information
| Provider Information | |||||||||
| NPI: | 1194024497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKEOWN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CARLISLE | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687366 | ||||||||
| FaxNumber: | 5025687114 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 HIGHWAY 70 N | ||||||||
| Address2: | |||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378574001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232723099 | ||||||||
| FaxNumber: | 4232726591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 15721 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 15721 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1525126 | 05 | TN | MEDICAID |