=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952691057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JLS MEDICAL ENTERPRISES PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2011
-----------------------------------------------------
Last Update Date | 12/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 UNIVERSITY DR SUITE 201B
-----------------------------------------------------
City | PRESTONSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41653-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-886-4277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 UNIVERSITY DR SUITE 201B
-----------------------------------------------------
City | PRESTONSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41653-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-886-4277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | JOANNA LOURDES SANTIESTEBAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 606-886-1162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------