Provider Demographics
NPI:1235412982
Name:JOHNSON, KELLY JACKSON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JACKSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4787 ALBEN BARKLEY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6789
Mailing Address - Country:US
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:270-441-0079
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-997-1187
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant