MEDICARE: BRUCE DAVENPORT

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	101YP2500X	Professional Counselor	LPC0000000729	TN

General Provider Information

NPI Number	:	1790552255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE DAVENPORT

Provider Business Mailing Address
First Line	:	1820 PAUL DR
Second Line	:
City	:	JEFFERSON CITY
State	:	TN
Zip	:	37760-5229
Country	:	US
Telephone Number	:	423-312-4687
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 PAUL DR
Second Line	:
City	:	JEFFERSON CITY
State	:	TN
Zip	:	37760-5229
Country	:	US
Telephone Number	:	423-312-4687
Fax Number	:

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

Provider Enumeration Date	:	12/05/2023
Last Update Date	:	12/05/2023

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Directions to “ BRUCE DAVENPORT ” Practice Location

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