Healthcare Provider Details

I. General information

NPI: 1669656849
Provider Name (Legal Business Name): JESSICA N B EASTERLING M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2007
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 FRANKFORT RD STE 101
SHELBYVILLE KY
40065-7401
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-1435
US

V. Phone/Fax

Practice location:
  • Phone: 502-647-5468
  • Fax: 502-732-7136
Mailing address:
  • Phone: 502-588-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number43516
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43516
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: