Provider Demographics
NPI:1083872774
Name:KAVANAUGH, JESSICA L (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:COLYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2250 LEESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1052
Mailing Address - Country:US
Mailing Address - Phone:859-233-4511
Mailing Address - Fax:859-281-3801
Practice Address - Street 1:2250 LEESTOWN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1052
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:859-281-3801
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-094893208100000X
KY48980208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100116160Medicaid
IN201002790Medicaid
OH3040999Medicaid
KY7100116160Medicaid