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General NPI Number Information
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NPI Number | 1144888231
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Entity Type | Individual
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Provider Name | JESSICA THIBAULT PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/03/2019
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 201 ABRAHAM FLEXNER WAY STE 100
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City | LOUISVILLE
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State | KY
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Zip | 40202-3841
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Country | US
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Telephone | 502-587-8222
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 909
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City | LOUISVILLE
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State | KY
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Zip | 40201-0909
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Country | US
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Telephone | 502-588-0328
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Fax | 502-588-0328
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-09012
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | TC094
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License Number State | KY
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