Healthcare Provider Details

I. General information

NPI: 1437505906
Provider Name (Legal Business Name): JESSE AULT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 WOLF RIVER BLVD STE 200
GERMANTOWN TN
38138-1755
US

IV. Provider business mailing address

PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-3630
  • Fax: 901-747-4149
Mailing address:
  • Phone:
  • Fax: 901-328-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21343
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: