=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124960042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ROSS JEROME NAGLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2026
-----------------------------------------------------
Last Update Date | 04/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 TIMBER CREEK DR
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-4291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-554-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 LAUDERDALE AVE
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38019-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-949-9697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 12554
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------