Provider Demographics
NPI:1316258437
Name:STEWART-JAYNES, MARISSA LAYNE (MD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LAYNE
Last Name:STEWART-JAYNES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:L
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2200 JEFFERSON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7102
Mailing Address - Country:US
Mailing Address - Phone:419-251-2032
Mailing Address - Fax:
Practice Address - Street 1:6321 KENTUCKY DAM RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-9471
Practice Address - Country:US
Practice Address - Phone:270-898-8415
Practice Address - Fax:270-898-4753
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45314207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100176770Medicaid
KYK014973Medicare PIN
KYK014971Medicare PIN
KY7100176770Medicaid
KYK014970Medicare PIN