Basic Information
| Provider Information | |||||||||
| NPI: | 1588920300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MAUDELLA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | APRN, PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 ROCKWOOD LN | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064365761 | ||||||||
| FaxNumber: | 6064365797 | ||||||||
| Practice Location | |||||||||
| Address1: | 3470 HIGHWAY 80 W | ||||||||
| Address2: | |||||||||
| City: | EMMALENA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417408854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067859377 | ||||||||
| FaxNumber: | 6067859371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007270 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 3007270 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 710022650 | 05 | KY | MEDICAID | K073146 | 01 | KY | MEDICARE | OTHER |