Healthcare Provider Details

I. General information

NPI: 1760949861
Provider Name (Legal Business Name): JESSICA PUCKETT L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 PEABODY AVE
MEMPHIS TN
38104-3500
US

IV. Provider business mailing address

220 HILLDALE LN
MILLINGTON TN
38053-0368
US

V. Phone/Fax

Practice location:
  • Phone: 901-321-5803
  • Fax:
Mailing address:
  • Phone: 901-641-6830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU0000000145
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: