Healthcare Provider Details

I. General information

NPI: 1982324182
Provider Name (Legal Business Name): JEFFERSON COUNTY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 LAURA LEE DR
WHITE PINE TN
37890
US

IV. Provider business mailing address

914 INDUSTRIAL PARK RD
DANDRIDGE TN
37725-4700
US

V. Phone/Fax

Practice location:
  • Phone: 865-327-4100
  • Fax:
Mailing address:
  • Phone: 865-397-3163
  • Fax: 865-397-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER LOUIS MYNATT
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 865-397-3163