Healthcare Provider Details

I. General information

NPI: 1942357942
Provider Name (Legal Business Name): JILL WALLNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 W FIRST ST SUITE 101
CROSSVILLE TN
38555-4443
US

IV. Provider business mailing address

58 W FIRST ST
CROSSVILLE TN
38555-4443
US

V. Phone/Fax

Practice location:
  • Phone: 931-456-7992
  • Fax: 931-707-1089
Mailing address:
  • Phone: 931-456-7992
  • Fax: 931-707-1089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberMD 27432
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD 27432
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: