Basic Information
| Provider Information | |||||||||
| NPI: | 1316986433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAWFORD | ||||||||
| FirstName: | JACKY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 VALLEYDALE LN | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407449145 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 TRILLIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065281212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35808 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083X0100X | 35808 | KY | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64016884 | 05 | KY | MEDICAID | 000000184103 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |