Basic Information
| Provider Information | |||||||||
| NPI: | 1295119915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARLEN | ||||||||
| FirstName: | JERRI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRBY | ||||||||
| OtherFirstName: | JERRI | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | 5022870662 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S JOE B HALL AVE | ||||||||
| Address2: | |||||||||
| City: | SHEPHERDSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401656009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | 5022670662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 71005617A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 3009543 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100353660 | 05 | KY | MEDICAID |