=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033370457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER STEWART BLAKELY LOU DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2008
-----------------------------------------------------
Last Update Date | 02/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 UNION AVE DEPARTMENT OF PEDIATRIC DENTISTRY
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-448-6260
-----------------------------------------------------
Fax | 901-448-3817
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 875 UNION AVE DEPARTMENT OF PEDIATRIC DENTISTRY
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-448-6260
-----------------------------------------------------
Fax | 901-448-3817
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401413498
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 9605
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 3921
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------