Healthcare Provider Details

I. General information

NPI: 1295620557
Provider Name (Legal Business Name): FAMILY CLINIC AT THE LAKE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 PICKWICK ST
SAVANNAH TN
38372-3519
US

IV. Provider business mailing address

PO BOX 55
SAVANNAH TN
38372-0055
US

V. Phone/Fax

Practice location:
  • Phone: 731-925-3354
  • Fax: 731-438-3581
Mailing address:
  • Phone: 731-925-3354
  • Fax: 731-438-3581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ELLANIKOLE JACKSON
Title or Position: OWNER
Credential: NP
Phone: 901-500-8629