Healthcare Provider Details

I. General information

NPI: 1790425080
Provider Name (Legal Business Name): JANA BRIELLE LACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BROWN AVE STE 103
CROSSVILLE TN
38555-7740
US

IV. Provider business mailing address

84 EDWARDS RD
CROSSVILLE TN
38571-0599
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-8861
  • Fax: 865-374-2116
Mailing address:
  • Phone: 931-787-8307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: