1093124133 NPI number — JESSICA SOUTHERS

Table of content: JESSICA SOUTHERS (NPI 1093124133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093124133 NPI number — JESSICA SOUTHERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHERS
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1093124133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 681478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-1478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-591-6590
Provider Business Mailing Address Fax Number:
615-591-6600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 MULBERRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELMER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38375-2336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-645-4501
Provider Business Practice Location Address Fax Number:
731-645-4893
Provider Enumeration Date:
08/02/2014

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:  P13039 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 14648 , 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)

  • Identifier: Q029723 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com