Provider Demographics
NPI:1043412893
Name:STEVENS, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 TANNER WAY
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-8302
Mailing Address - Country:US
Mailing Address - Phone:865-376-6272
Mailing Address - Fax:
Practice Address - Street 1:1855 TANNER WAY STE 200
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8331
Practice Address - Country:US
Practice Address - Phone:865-376-6272
Practice Address - Fax:865-374-2100
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-123950207Q00000X
IL125-053128390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
833230OtherMEDICARE GROUP #
TNQ057477Medicaid