Provider Demographics
NPI:1043526064
Name:WILLIS, JENNIFER R (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:WILLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:LIPSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:601 S FLOYD ST STE 700
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1845
Practice Address - Country:US
Practice Address - Phone:502-629-7181
Practice Address - Fax:502-629-6957
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28178246A163WD0400X
KY3006899363L00000X
KY1083742163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000772805OtherANTHEM-NMFM
KY137155OtherSIHO - NMFM
KY50040392OtherPASSPORT - NMFM
IN201009490Medicaid
KY7100205410Medicaid
KY50040392OtherPASSPORT - NMFM