Healthcare Provider Details

I. General information

NPI: 1588321830
Provider Name (Legal Business Name): AMBER JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1254 US 31W BYP
BOWLING GREEN KY
42101-2577
US

IV. Provider business mailing address

1254 US 31W BYP
BOWLING GREEN KY
42101-2577
US

V. Phone/Fax

Practice location:
  • Phone: 270-777-6321
  • Fax:
Mailing address:
  • Phone: 270-777-6321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: