Healthcare Provider Details

I. General information

NPI: 1346624962
Provider Name (Legal Business Name): JASMAINE THEOBALD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE SUITE 103
PADUCAH KY
42003-3817
US

IV. Provider business mailing address

2700 STANLEY GAULT PKWY STE 129
LOUISVILLE KY
40223-5176
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-4860
  • Fax: 270-415-4862
Mailing address:
  • Phone: 502-253-4900
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009523
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: