MEDICARE: JACLYN MARIE CECILIA GRIFFITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	230136	TN
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	32373	TN

General Provider Information

NPI Number	:	1023730298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MARIE CECILIA GRIFFITH

Provider Business Mailing Address
First Line	:	1723 MOUNT VERNON DR NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3539
Country	:	US
Telephone Number	:	423-473-2633
Fax Number	:	423-473-2643

Provider Business Practice Location Address
First Line	:	1723 MOUNT VERNON DR NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3539
Country	:	US
Telephone Number	:	423-473-2633
Fax Number	:	423-473-2643

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	01/24/2024

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