Basic Information
| Provider Information | |||||||||
| NPI: | 1518358431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 WOODLAND DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1239 WOODLAND DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2015 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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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 | 363LP0808X | 3008857 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 3008857 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3008857 | 01 | KY | LISCENSE | OTHER |