Provider Demographics
NPI:1316711377
Name:THOMAS, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:THOMAS
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:PO BOX 90007
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9007
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:
Practice Address - Street 1:5575 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-6800
Practice Address - Country:US
Practice Address - Phone:270-282-7088
Practice Address - Fax:270-782-6438
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
KYPA3386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical