Healthcare Provider Details

I. General information

NPI: 1740639962
Provider Name (Legal Business Name): JABBOK TREATMENT CENTER, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 IRWIN ST
SAVANNAH TN
38372-3084
US

IV. Provider business mailing address

40 IRWIN ST
SAVANNAH TN
38372-3084
US

V. Phone/Fax

Practice location:
  • Phone: 731-727-5603
  • Fax: 731-925-2114
Mailing address:
  • Phone: 731-727-5603
  • Fax: 731-925-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number207QA0401X
License Number StateTN

VIII. Authorized Official

Name: JACQUELINE D IRWIN
Title or Position: OWNER/COO
Credential:
Phone: 77316167753