MEDICARE: JESS G. EVANS PH.D

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	247ZC0005X	Clinical Laboratory Director (Non-physician)	ML0000023356	TN

General Provider Information

NPI Number	:	1336549971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESS G. EVANS PH.D

Provider Business Mailing Address
First Line	:	1701 CENTURY CENTER CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-8975
Country	:	US
Telephone Number	:	901-432-8605
Fax Number	:	901-844-8668

Provider Business Practice Location Address
First Line	:	1701 CENTURY CENTER CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-8975
Country	:	US
Telephone Number	:	901-432-8605
Fax Number	:	901-844-8668

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

Provider Enumeration Date	:	09/02/2014
Last Update Date	:	09/02/2014

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