Basic Information
| Provider Information | |||||||||
| NPI: | 1720624356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CLINT HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420016771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704507229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705752100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3014213 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.