Healthcare Provider Details

I. General information

NPI: 1982428272
Provider Name (Legal Business Name): JENNIFER TIBBEN AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER YACHANIN AGPCNP

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 22392
KNOXVILLE TN
37933-0392
US

IV. Provider business mailing address

PO BOX 22392
KNOXVILLE TN
37933-0392
US

V. Phone/Fax

Practice location:
  • Phone: 520-820-7918
  • Fax:
Mailing address:
  • Phone: 520-820-7918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number37499
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: