Basic Information
| Provider Information | |||||||||
| NPI: | 1891834735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CULVER | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 S DUPONT SQ | ||||||||
| Address2: | STE C | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 S DUPONT SQ | ||||||||
| Address2: | STE C | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 05/14/2015 | ||||||||
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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 | 163W00000X | 28193680A | IN | N | Nursing Service Providers | Registered Nurse | 163W00000X | 1098624 | KY | N | Nursing Service Providers | Registered Nurse | 363LW0102X | 3003956 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LA2200X | 3003956 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7100069160 | 05 | KY | MEDICAID | P00895264 | 01 | KY | RAILROAD MEDICARE | OTHER | P00685745 | 01 | KY | RAILROAD MEDICARE | OTHER |