Individual
MRS. JACQUELINE EILEEN DAVIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3 AUDUBON PLAZA DR STE 430, LOUISVILLE, KY 40217
(502) 636-4900
(502) 636-4901
Mailing address
PO BOX 776351, CHICAGO, IL 60677-6351
(502) 272-5063
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50022601
PASSPORT HEALTH PLAN
KY
05
—
7100054590
—
KY
Enumeration date
03/31/2008
Last updated
03/21/2019
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