Healthcare Provider Details

I. General information

NPI: 1174142327
Provider Name (Legal Business Name): JENNA MAE DEDEKER SHOEMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BLACKFORD ST
CHATTANOOGA TN
37403-1405
US

IV. Provider business mailing address

3849 WILHOIT RD
APISON TN
37302-9783
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-6101
  • Fax:
Mailing address:
  • Phone: 423-400-4487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number76995
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: