Provider Demographics
NPI:1871813550
Name:DAVIS, JACQUELINE (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:LANHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:200 CLINIC DRIVEV
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:270-824-3682
Mailing Address - Fax:270-824-3675
Practice Address - Street 1:1804 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6016
Practice Address - Country:US
Practice Address - Phone:812-288-2488
Practice Address - Fax:812-288-6603
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003616A363L00000X
KY49086363L00000X
KY3006612363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3006612OtherLICENSE NUMBER
KYK151030OtherMEDICARE PTAN
IN71003616AOtherLICENSE NUMBER
KYK151030OtherMEDICARE PTAN