Basic Information
| Provider Information | |||||||||
| NPI: | 1881150100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892371 | ||||||||
| FaxNumber: | 7402893545 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 US HIGHWAY 23 | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402893508 | ||||||||
| FaxNumber: | 7402898951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.025703 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0372064 | 05 | OH | MEDICAID | 417733 | 01 | OH | NURSING LICENSE | OTHER |