Healthcare Provider Details

I. General information

NPI: 1619687712
Provider Name (Legal Business Name): CASSIE S JESSIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 COMMERCE DR
GREENSBURG KY
42743-1402
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 270-932-2424
  • Fax: 270-932-2522
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3018134
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: