Provider Demographics
NPI:1033638499
Name:HUBBARD, JEREMY RAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RAY
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063
Mailing Address - Country:US
Mailing Address - Phone:731-671-5620
Mailing Address - Fax:
Practice Address - Street 1:728 W SHERROD AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3024
Practice Address - Country:US
Practice Address - Phone:901-476-7779
Practice Address - Fax:901-475-6008
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038660Medicaid