Healthcare Provider Details

I. General information

NPI: 1215491501
Provider Name (Legal Business Name): JACQUELYN MARGARET KOEPP APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 NEW HOLT RD STE C
PADUCAH KY
42001-7506
US

IV. Provider business mailing address

5245 STATE ROUTE 97
MAYFIELD KY
42066-7347
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-1010
  • Fax:
Mailing address:
  • Phone: 270-804-0872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3013078
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: