=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780351106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYANNA JEPSEN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2021
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8800 SMYRNA PKWY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40228-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-694-2956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4017 BALLARD WOODS DR
-----------------------------------------------------
City | SMITHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40068-9324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-718-3670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A04310
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------