Provider Demographics
NPI:1073092185
Name:WOODALL, AMANDA NICOLA JACKSON (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLA JACKSON
Last Name:WOODALL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4233
Mailing Address - Country:US
Mailing Address - Phone:901-566-1002
Mailing Address - Fax:901-566-1951
Practice Address - Street 1:8130 COUNTRY VILLAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2087
Practice Address - Country:US
Practice Address - Phone:901-308-2915
Practice Address - Fax:901-308-2924
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN197904363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health