Healthcare Provider Details

I. General information

NPI: 1881573251
Provider Name (Legal Business Name): MELISSA HENNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3414 RIVERSIDE DR
JACKSON TN
38301-9130
US

IV. Provider business mailing address

3414 RIVERSIDE DR
JACKSON TN
38301-9130
US

V. Phone/Fax

Practice location:
  • Phone: 731-217-0885
  • Fax:
Mailing address:
  • Phone: 731-217-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number39885
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number231505
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: