Healthcare Provider Details

I. General information

NPI: 1417768060
Provider Name (Legal Business Name): JAMIE A. WATHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CRANES ROOST CT
ELIZABETHTOWN KY
42701-3650
US

IV. Provider business mailing address

207B FAIRGROUNDS RD
HARDINSBURG KY
40143-2585
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-2605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number257000
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: