Basic Information
| Provider Information | |||||||||
| NPI: | 1932375391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERNHAM | ||||||||
| FirstName: | JENELLE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARTER | ||||||||
| OtherFirstName: | JENELLE | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23229 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423043229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881330 | ||||||||
| FaxNumber: | 2706881338 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 MAYFAIR DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423014569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706881352 | ||||||||
| FaxNumber: | 2706834313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001008A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1009 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100100710 | 05 | KY | MEDICAID | 300004679 | 05 | IN | MEDICAID |