Healthcare Provider Details

I. General information

NPI: 1417219189
Provider Name (Legal Business Name): WELLFIT MEDICINE AND NUTRITION JACKSON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EXECUTIVE DR
JACKSON TN
38305-2318
US

IV. Provider business mailing address

101 EXECUTIVE DR
JACKSON TN
38305-2318
US

V. Phone/Fax

Practice location:
  • Phone: 731-300-3372
  • Fax: 731-300-3374
Mailing address:
  • Phone: 731-300-3372
  • Fax: 731-300-3374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45520
License Number StateTN

VIII. Authorized Official

Name: JEREMY M DRAPER
Title or Position: OWNER
Credential: MD
Phone: 731-300-3372