Healthcare Provider Details

I. General information

NPI: 1336198829
Provider Name (Legal Business Name): NORMA JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1494 STUART RD.
CLEVELAND TN
37312
US

IV. Provider business mailing address

6170 SHALLOWFORD RD STE 101
CHATTANOOGA TN
37421-1892
US

V. Phone/Fax

Practice location:
  • Phone: 423-648-7699
  • Fax: 423-648-7695
Mailing address:
  • Phone: 423-648-4500
  • Fax: 423-855-7563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN6701
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: