Basic Information
| Provider Information | |||||||||
| NPI: | 1376607358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVY | ||||||||
| FirstName: | JARRETT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 CENTERPOINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379321984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659857068 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1107 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597453500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PA157 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | KY | MEDICAID |