Provider Demographics
NPI:1003954595
Name:JACKS, BEVERLY J (CNM, APRN)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:J
Last Name:JACKS
Suffix:
Gender:F
Credentials:CNM, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7201
Mailing Address - Country:US
Mailing Address - Phone:423-702-5581
Mailing Address - Fax:423-702-5605
Practice Address - Street 1:6116 SHALLOWFORD RD
Practice Address - Street 2:SUITE 117
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7201
Practice Address - Country:US
Practice Address - Phone:423-702-5581
Practice Address - Fax:423-702-5605
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN05511367A00000X
TN5511363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3495196Medicaid
TN3495196Medicare UPIN
TN3495196Medicaid