Provider Demographics
NPI:1033560826
Name:PODIATRY CLINIC OF JACKSON PLLC
Entity Type:Organization
Organization Name:PODIATRY CLINIC OF JACKSON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADM/OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-427-5581
Mailing Address - Street 1:657 SKYLINE DR
Mailing Address - Street 2:STE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3903
Mailing Address - Country:US
Mailing Address - Phone:731-427-5581
Mailing Address - Fax:731-427-8257
Practice Address - Street 1:657 SKYLINE DR
Practice Address - Street 2:STE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3903
Practice Address - Country:US
Practice Address - Phone:731-427-5581
Practice Address - Fax:731-427-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM213213E00000X, 213EP1101X, 213ER0200X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7553830001Medicare NSC