Healthcare Provider Details

I. General information

NPI: 1013696798
Provider Name (Legal Business Name): JACLYN SHIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN GERARD

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 E CHESTNUT ST
LOUISVILLE KY
40202-1821
US

IV. Provider business mailing address

205 SUNSET DR
LAWRENCEBURG KY
40342-1458
US

V. Phone/Fax

Practice location:
  • Phone: 502-494-9521
  • Fax:
Mailing address:
  • Phone: 502-494-9521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number1138276
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4008949
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: