Provider Demographics
NPI:1154493237
Name:DITTES, JENNIFER GEORGE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GEORGE
Last Name:DITTES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 NEW HIGHWAY 52 E
Mailing Address - Street 2:
Mailing Address - City:WESTMORELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37186-5060
Mailing Address - Country:US
Mailing Address - Phone:615-644-2000
Mailing Address - Fax:615-644-2078
Practice Address - Street 1:1124 NEW HIGHWAY 52 E
Practice Address - Street 2:
Practice Address - City:WESTMORELAND
Practice Address - State:TN
Practice Address - Zip Code:37186-5060
Practice Address - Country:US
Practice Address - Phone:615-644-2000
Practice Address - Fax:615-644-2078
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN701PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4097035Medicaid
TN4097035Medicaid
TN4097035Medicaid