Healthcare Provider Details

I. General information

NPI: 1699176750
Provider Name (Legal Business Name): JACKIE WILSON-SHARP FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3826 NORMA RD
HUNTSVILLE TN
37756-4408
US

IV. Provider business mailing address

470 INDUSTRIAL LN
ONEIDA TN
37841-6294
US

V. Phone/Fax

Practice location:
  • Phone: 423-663-2920
  • Fax: 423-663-3989
Mailing address:
  • Phone: 423-286-4141
  • Fax: 423-286-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19046
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: