Healthcare Provider Details

I. General information

NPI: 1154556066
Provider Name (Legal Business Name): JENNIFER LYNN LUCAS C.O.T.A/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 HIGHLAND AVE
KNOXVILLE TN
37916-1112
US

IV. Provider business mailing address

2120 HIGHLAND AVE
KNOXVILLE TN
37916-1112
US

V. Phone/Fax

Practice location:
  • Phone: 865-525-4131
  • Fax:
Mailing address:
  • Phone: 865-525-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number1734
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: