Healthcare Provider Details

I. General information

NPI: 1821547308
Provider Name (Legal Business Name): JERRY NUNN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 SEARCY WAY
BOWLING GREEN KY
42103-7168
US

IV. Provider business mailing address

942 SEARCY WAY
BOWLING GREEN KY
42103-7168
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-8112
  • Fax: 270-781-8114
Mailing address:
  • Phone: 270-781-8112
  • Fax: 270-781-8114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number126239
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: