Healthcare Provider Details

I. General information

NPI: 1679139844
Provider Name (Legal Business Name): JESSE MICHAEL VANCE MD, PHARMD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 FLEMINGSBURG RD
MOREHEAD KY
40351-1015
US

IV. Provider business mailing address

245 FLEMINGSBURG RD
MOREHEAD KY
40351-1015
US

V. Phone/Fax

Practice location:
  • Phone: 606-780-5500
  • Fax: 606-780-2373
Mailing address:
  • Phone: 606-780-5500
  • Fax: 606-780-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number015939
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number49366
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number69688
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30911
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61041
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: