Healthcare Provider Details

I. General information

NPI: 1982151007
Provider Name (Legal Business Name): JENNIFER COPLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NICOLE RUSSELL

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6350 W ANDREW JOHNSON HWY
TALBOTT TN
37877-8605
US

IV. Provider business mailing address

6350 W ANDREW JOHNSON HWY DEPARTMENT 100
TALBOTT TN
37877-8605
US

V. Phone/Fax

Practice location:
  • Phone: 423-587-7337
  • Fax: 423-586-0614
Mailing address:
  • Phone: 800-355-3565
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11050 (LMSW)
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: