Healthcare Provider Details

I. General information

NPI: 1174872139
Provider Name (Legal Business Name): METHODIST LE BONHEUR COMMUNITY OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 STONEBRIDGE BLVD
JACKSON TN
38305-2165
US

IV. Provider business mailing address

1535 VANN DR
JACKSON TN
38305-2095
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5961
  • Fax:
Mailing address:
  • Phone: 731-499-0977
  • Fax: 731-499-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PAM DENISE BURNETT
Title or Position: MANAGER OF OPERATIONS
Credential:
Phone: 731-984-9963