Healthcare Provider Details

I. General information

NPI: 1922597087
Provider Name (Legal Business Name): JAKE MAJURE CHANDLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

3243 N HILL DR
TUPELO MS
38804-9787
US

V. Phone/Fax

Practice location:
  • Phone: 901-818-2160
  • Fax: 901-682-9443
Mailing address:
  • Phone: 601-562-5934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number894584
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24813
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901663
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: