Provider Demographics
NPI:1194720011
Name:WEBB, JACQUELYN KELLI (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:KELLI
Last Name:WEBB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:GREER
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2424 HARRODSBURG RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2106
Mailing Address - Country:US
Mailing Address - Phone:859-278-9492
Mailing Address - Fax:859-277-3027
Practice Address - Street 1:2424 HARRODSBURG RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2106
Practice Address - Country:US
Practice Address - Phone:859-278-9492
Practice Address - Fax:859-277-3027
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37483207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64084544Medicaid
KYI10933Medicare UPIN
KY1270414Medicare ID - Type Unspecified