Provider Demographics
NPI:1063294726
Name:KAN, JESSICA M (CLC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:KAN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18697 MILA MARIE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5387
Mailing Address - Country:US
Mailing Address - Phone:434-610-8376
Mailing Address - Fax:
Practice Address - Street 1:18697 MILA MARIE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5387
Practice Address - Country:US
Practice Address - Phone:434-610-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY232655174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN