Healthcare Provider Details

I. General information

NPI: 1578496006
Provider Name (Legal Business Name): JACINDA ADDINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WINDSOR AVE
BRISTOL TN
37620-2156
US

IV. Provider business mailing address

209 SHIRLEY DR
BRISTOL TN
37620-4826
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-3122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13142
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: