Healthcare Provider Details

I. General information

NPI: 1891860599
Provider Name (Legal Business Name): JODI A CONLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BELLEFONTE DR
GRAYSON KY
41143-1820
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-0669
  • Fax: 606-474-0376
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA355
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: