Healthcare Provider Details

I. General information

NPI: 1447467782
Provider Name (Legal Business Name): JESSICA RENEE WILSON CARSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 FOX RD SUITE 200
KNOXVILLE TN
37922-3383
US

IV. Provider business mailing address

235 WILLOW RUN
CLINTON TN
37716-2717
US

V. Phone/Fax

Practice location:
  • Phone: 865-690-5231
  • Fax: 865-691-4291
Mailing address:
  • Phone: 423-494-1128
  • Fax: 865-691-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6264
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: