1104107507 NPI number — MRS. JENNIFER CLARK RISEDEN FNP-BC

Table of content: MRS. JENNIFER CLARK RISEDEN FNP-BC (NPI 1104107507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104107507 NPI number — MRS. JENNIFER CLARK RISEDEN FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RISEDEN
Provider First Name:
JENNIFER
Provider Middle Name:
CLARK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104107507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 CANNON RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARDEN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28704-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-712-9191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 YORKSHIRE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28803-2796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-761-1710
Provider Business Practice Location Address Fax Number:
828-505-8345
Provider Enumeration Date:
08/30/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16065 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5017987 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 16065 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 460643559 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".