Basic Information
| Provider Information | |||||||||
| NPI: | 1205165156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705861969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1112 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421342371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705861969 | ||||||||
| FaxNumber: | 2705861914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2009 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
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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 | 363LF0000X | 3006240 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100153600 | 05 | KY | MEDICAID |