NPI |
1447745526 |
The last name of the provider. If the provider is an individual, this is the legal name. |
Entity Type Code |
1 |
The first name of the provider, if the provider
is an individual. |
Provider Last Name Legal Name |
FOLEY |
The middle name of the provider, if the provider
is an individual. |
Provider First Name |
JENNIFER |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider Middle Name |
L |
Other last name by which the provider being identified is or has been known. |
Provider First Line Business Practice Location Address |
650 JOEL DR |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
Provider Business Practice Location Address City Name |
FORT CAMPBELL |
Other middle name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider middle name’’ if the provider
is or has been known by a different last name only. |
Provider Business Practice Location Address State Name |
KY |
The other abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider Business Practice Location Address Postal Code |
422235318 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address Telephone Number |
2704610570 |
The city name in the location address of the provider being identified. |
Provider Enumeration Date |
6/29/2018 |
The State code in the location of the provider
being identified. |
Last Update Date |
3/21/2023 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
1041C0700X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
N |
The date the provider was assigned a unique identifier (assigned an NPI). |
Healthcare Provider Taxonomy Code 2 |
1041C0700X |
The date that a record was last updated or changed. |
Provider License Number 2 |
98905 |
The code designating the provider’s gender if the provider is a person. |
Provider License Number State Code 2 |
CA |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 2 |
N |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Healthcare Provider Taxonomy Code 3 |
1041C0700X |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider License Number 3 |
68562 |
|
Provider License Number State Code 3 |
TX |
|
Healthcare Provider Primary Taxonomy Switch 3 |
Y |
|
Is Sole Proprietor |
N |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
NPI Certification Date |
3/21/2023 |
|