Healthcare Provider Details

I. General information

NPI: 1063113660
Provider Name (Legal Business Name): LAJACQUA RIVERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2634 N CENTRAL AVE
HUMBOLDT TN
38343-1534
US

IV. Provider business mailing address

11 RUSHWOOD DR
JACKSON TN
38305-2145
US

V. Phone/Fax

Practice location:
  • Phone: 731-324-1526
  • Fax: 731-324-1534
Mailing address:
  • Phone: 731-326-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number37150
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0000242729
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: