Provider Demographics
NPI:1093448318
Name:WAKE, MARLENA
Entity Type:Individual
Prefix:
First Name:MARLENA
Middle Name:
Last Name:WAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 BANCORP SOUTH PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7582
Mailing Address - Country:US
Mailing Address - Phone:731-660-8781
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:614 CARRIAGE HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4238
Practice Address - Country:US
Practice Address - Phone:731-668-4449
Practice Address - Fax:731-660-8739
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8077225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant