Basic Information
| Provider Information | |||||||||
| NPI: | 1922067677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODCOCK | ||||||||
| FirstName: | JINNY | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VICROY | ||||||||
| OtherFirstName: | JINNY | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2040 REGENCY RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405032331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592761946 | ||||||||
| FaxNumber: | 8592761947 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 BULL LEA RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592468000 | ||||||||
| FaxNumber: | 8592468032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1041085 | KY | N | Nursing Service Providers | Registered Nurse | 364SP0809X | 3002819 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 000000368074 | 01 | ANTHEM BCBS | OTHER | MV1651466 | 01 | DEA | OTHER | 30610026 | 05 | KY | MEDICAID |