1063915726 NPI number — DR. ALLISON JILL CRISP DPT, MTC

Table of content: DR. ALLISON JILL CRISP DPT, MTC (NPI 1063915726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063915726 NPI number — DR. ALLISON JILL CRISP DPT, MTC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISP
Provider First Name:
ALLISON
Provider Middle Name:
JILL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT, MTC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRISP
Provider Other First Name:
JILL
Provider Other Middle Name:
CLARK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT, MTC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063915726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 AVALON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37303-4042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-506-4961
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 AVALON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37303-4042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-506-4961
Provider Business Practice Location Address Fax Number:
423-745-7132
Provider Enumeration Date:
03/08/2018

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: 225100000X , with the licence number:  8657 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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