=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588773188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 11/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10621 CHEVY DR STE A
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37922-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-966-1934
-----------------------------------------------------
Fax | 423-566-5896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10621 CHEVY DR STE A
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37922-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-966-1934
-----------------------------------------------------
Fax | 423-566-5896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICKOLA S JEFFERSON
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 865-966-1934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 6167
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------