Healthcare Provider Details

I. General information

NPI: 1629126321
Provider Name (Legal Business Name): JACKIE A CHURCH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 OVERLOOK DR STE 200
LEBANON VA
24266-3436
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 276-883-5900
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax: 423-282-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5018685
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number143764
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN12537
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024187900
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: