Healthcare Provider Details

I. General information

NPI: 1952504938
Provider Name (Legal Business Name): JENNIFER LYNN SULLIVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE SUITE 300
MEMPHIS TN
38104-6638
US

IV. Provider business mailing address

PO BOX 1000 DEPT # 457
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-2918
  • Fax: 901-266-6427
Mailing address:
  • Phone: 901-448-2918
  • Fax: 901-266-6427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number51617
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: