Basic Information
| Provider Information | |||||||||
| NPI: | 1235412982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4787 ALBEN BARKLEY DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420016789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704429461 | ||||||||
| FaxNumber: | 2704410079 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 LINCOLN DR | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629486334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189976800 | ||||||||
| FaxNumber: | 6189971187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
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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 | 363A00000X | PA1637 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.