Provider Demographics
NPI:1417768060
Name:WATHEN, JAMIE A
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:WATHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207B FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:HARDINSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40143-2585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 CRANES ROOST CT
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3650
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2570001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical