Healthcare Provider Details

I. General information

NPI: 1114882875
Provider Name (Legal Business Name): TRISTA JYNON HUDDLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W DIXIE AVE
ELIZABETHTOWN KY
42701-1702
US

IV. Provider business mailing address

308 W DIXIE AVE
ELIZABETHTOWN KY
42701-1702
US

V. Phone/Fax

Practice location:
  • Phone: 270-234-0003
  • Fax: 270-360-0840
Mailing address:
  • Phone: 270-234-0003
  • Fax: 270-360-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number303039
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number286253
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: