Provider Demographics
NPI:1194024497
Name:MCKEOWN, JENNIFER CARLISLE (ANP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CARLISLE
Last Name:MCKEOWN
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7366
Mailing Address - Fax:502-568-7114
Practice Address - Street 1:109 HIGHWAY 70 N
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-4001
Practice Address - Country:US
Practice Address - Phone:423-272-3099
Practice Address - Fax:423-272-6591
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15721363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525126Medicaid
TN1035I08990Medicare PIN