Provider Demographics
NPI:1033461447
Name:CHILDERS, JENNIFER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 MACON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-6168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 MARKET BLVD STE 103
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2360
Practice Address - Country:US
Practice Address - Phone:901-850-1150
Practice Address - Fax:901-850-1102
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant