Provider Demographics
NPI:1285729368
Name:BLUES, JACKELYN N (PA-C)
Entity type:Individual
Prefix:
First Name:JACKELYN
Middle Name:N
Last Name:BLUES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 603
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1471
Mailing Address - Country:US
Mailing Address - Phone:859-277-2211
Mailing Address - Fax:859-277-7575
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 603
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1471
Practice Address - Country:US
Practice Address - Phone:859-277-2211
Practice Address - Fax:859-277-7575
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA247363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002473Medicaid
KY970020899OtherRR MEDICARE
KY970020899OtherRR MEDICARE
KY95002473Medicaid
KYS89956Medicare UPIN
KY0169OtherMEDICARE GROUP ID
KYCB5773OtherRR MEDICARE GROUP
KY0091249Medicare PIN
KYASC1019OtherMEDICARE ASC GROUP
KY970020899OtherRR MEDICARE
KY36000818OtherMEDICAID ASC GROUP