Healthcare Provider Details

I. General information

NPI: 1982597720
Provider Name (Legal Business Name): JESSICA REVELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date: 09/30/2026
Reactivation Date: 10/07/2026

III. Provider practice location address

41 STONEBROOK PL
JACKSON TN
38305-3637
US

IV. Provider business mailing address

41 STONEBROOK PL
JACKSON TN
38305-3637
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-0912
  • Fax:
Mailing address:
  • Phone: 731-661-0912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number49950
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: