Provider Demographics
NPI:1033370457
Name:LOU, JENNIFER STEWART BLAKELY (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STEWART BLAKELY
Last Name:LOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:STEWART
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:875 UNION AVE
Mailing Address - Street 2:DEPARTMENT OF PEDIATRIC DENTISTRY
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3513
Mailing Address - Country:US
Mailing Address - Phone:901-448-6260
Mailing Address - Fax:901-448-3817
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:DEPARTMENT OF PEDIATRIC DENTISTRY
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3513
Practice Address - Country:US
Practice Address - Phone:901-448-6260
Practice Address - Fax:901-448-3817
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014134981223P0221X, 1223P0221X
TN96051223P0221X
AR39211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry