Healthcare Provider Details

I. General information

NPI: 1083143671
Provider Name (Legal Business Name): JACQUELINE RENEE BOOTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OAK RIDGE TPKE STE C100
OAK RIDGE TN
37830-6927
US

IV. Provider business mailing address

800 OAK RIDGE TPKE STE C100
OAK RIDGE TN
37830-6927
US

V. Phone/Fax

Practice location:
  • Phone: 865-483-2288
  • Fax: 865-482-4400
Mailing address:
  • Phone: 865-483-2288
  • Fax: 865-482-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number009101
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number74273
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: