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General NPI Number Information
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NPI Number | 1295620557
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Entity Type | Organization
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Legal Business Name | FAMILY CLINIC AT THE LAKE PLLC
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Dates
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Enumeration Date | 06/09/2025
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Last Update Date | 06/09/2025
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Provider Practice Location Address
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Address Line | 1440 PICKWICK ST
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City | SAVANNAH
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State | TN
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Zip | 38372-3519
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Country | US
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Telephone | 731-925-3354
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Fax | 731-438-3581
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Provider Business Mailing Address
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Address Line | PO BOX 55
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City | SAVANNAH
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State | TN
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Zip | 38372-0055
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Country | US
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Telephone | 731-925-3354
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Fax | 731-438-3581
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Authorized Official
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Title or Position | OWNER
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Name | ELLANIKOLE JACKSON
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Credential | NP
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Telephone | 901-500-8629
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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