Basic Information
| Provider Information | |||||||||
| NPI: | 1679976518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMBS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MITCHELL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706519696 | ||||||||
| FaxNumber: | 2706510385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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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 | 363LP0200X | 3008912 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100336280 | 05 | KY | MEDICAID |