1306806690 NPI number — JENNIFER LEANN MOSER

Table of content: JENNIFER LEANN MOSER (NPI 1306806690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306806690 NPI number — JENNIFER LEANN MOSER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSER
Provider First Name:
JENNIFER
Provider Middle Name:
LEANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306806690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7947 EUREKA RD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37310-5107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-290-4801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2333 MCCALLIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37404-3258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-698-6061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  APN11895 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1512211 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4118347 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".