Provider Demographics
NPI:1225452550
Name:GULISH, JESSE (OPA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GULISH
Suffix:
Gender:M
Credentials:OPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4429
Practice Address - Street 1:205 HOSPITAL DR STE A
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN820246ZX2200X, 363A00000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640Medicaid