Basic Information
| Provider Information | |||||||||
| NPI: | 1306204490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSIE | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | TABOR | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N RACE ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706514444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1084 VETERANS MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | SCOTTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421649602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023731232 | ||||||||
| FaxNumber: | 2702373139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2016 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3010029 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3010029 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | F1215390 | 01 | KY | AMERICAN ACADEMY OF NURSE PRACTITIONERS--FAMILY | OTHER | 7100474280 | 05 | KY | MEDICAID | 3010029 | 01 | KY | KY LICENSE | OTHER |