=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245665868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANTZEN MOSS L.P.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2013
-----------------------------------------------------
Last Update Date | 09/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4039 HIGHLAND ST SUITE 2
-----------------------------------------------------
City | MILAN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38358-3483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-723-1327
-----------------------------------------------------
Fax | 731-660-8739
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1804 HIGHWAY 45 BYP SUITE 604
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-660-7971
-----------------------------------------------------
Fax | 731-660-8739
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 65174
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------