Basic Information
| Provider Information | |||||||||
| NPI: | 1376694935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 WIND HAVEN DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 WIND HAVEN DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 12/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0427 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 30615058 | 05 | KY | MEDICAID |