Healthcare Provider Details

I. General information

NPI: 1568726859
Provider Name (Legal Business Name): MAKAYLA ELIZABETH JESSIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E FRAZIER AVE
COLUMBIA KY
42728-1915
US

IV. Provider business mailing address

130 SOUTHERN SCHOOL RD
SOMERSET KY
42501-3223
US

V. Phone/Fax

Practice location:
  • Phone: 270-384-4719
  • Fax:
Mailing address:
  • Phone: 606-679-4782
  • Fax: 606-677-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: