Basic Information
| Provider Information | |||||||||
| NPI: | 1477854115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STINSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 NATCHEZ TRACE AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707457246 | ||||||||
| FaxNumber: | 2702822027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1216 N RACE ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707457246 | ||||||||
| FaxNumber: | 2702822027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2010 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3006704 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 6704P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3006704 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100149700 | 05 | KY | MEDICAID |