Healthcare Provider Details

I. General information

NPI: 1073342481
Provider Name (Legal Business Name): JENNIFER LAUREN HEGLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 5TH ST STE 310
BRISTOL TN
37620-5919
US

IV. Provider business mailing address

179 BART GREEN DR APT 75
JOHNSON CITY TN
37615-6807
US

V. Phone/Fax

Practice location:
  • Phone: 865-909-7131
  • Fax:
Mailing address:
  • Phone: 423-534-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7532
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: