Healthcare Provider Details

I. General information

NPI: 1568918878
Provider Name (Legal Business Name): TRACEY JOLENE JENKINS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2016
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14821 DAYTON PIKE
SALE CREEK TN
37373-5752
US

IV. Provider business mailing address

6130 SHALLOWFORD RD STE 101
CHATTANOOGA TN
37421-7222
US

V. Phone/Fax

Practice location:
  • Phone: 423-486-9455
  • Fax:
Mailing address:
  • Phone: 423-664-4635
  • Fax: 423-702-7789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: