Basic Information
| Provider Information | |||||||||
| NPI: | 1669567137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDIN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 FLEMINGSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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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 | 363AM0700X | PA412 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA412 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | K032922 | 01 | KY | MEDICARE PTAN | OTHER | 95000386 | 05 | KY | MEDICAID | 37903705 | 01 | KY | MEDICAID LAB GRP | OTHER | 4000501 | 01 | KY | MEDICARE LAB GRP | OTHER | CB5773 | 01 | GA | RR MEDICARE GRP | OTHER | P00190999 | 01 | GA | RR MEDICARE PIN | OTHER |