Provider Demographics
NPI:1386250629
Name:RILEY, JESSICA ALEXANDRA (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALEXANDRA
Last Name:RILEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ALEXANDRA
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:90 GLENN EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-7136
Mailing Address - Country:US
Mailing Address - Phone:606-767-1066
Mailing Address - Fax:
Practice Address - Street 1:4201 SPRINGHURST BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6155
Practice Address - Country:US
Practice Address - Phone:502-290-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014210363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100291160Medicaid