Healthcare Provider Details

I. General information

NPI: 1699237248
Provider Name (Legal Business Name): JESSICA B GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 10/23/2022
Certification Date: 10/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 CHANCELLOR DR STE 120
CRESTVIEW HILLS KY
41017-3915
US

IV. Provider business mailing address

2865 CHANCELLOR DR STE 120
CRESTVIEW HILLS KY
41017-3915
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-5400
  • Fax: 859-578-3172
Mailing address:
  • Phone: 859-341-5400
  • Fax: 859-578-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.144445
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56641
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: