Provider Demographics
NPI:1245557859
Name:CONRAD-RENDON, JENNIFER LYN (NP-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYN
Last Name:CONRAD-RENDON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYN
Other - Last Name:RENDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4646 POPLAR AVE STE 128
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4409
Mailing Address - Country:US
Mailing Address - Phone:901-487-3814
Mailing Address - Fax:901-410-8345
Practice Address - Street 1:4646 POPLAR AVE STE 128
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4409
Practice Address - Country:US
Practice Address - Phone:901-487-3814
Practice Address - Fax:901-410-8345
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14921261QP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN152075Medicaid
TN10350I3799Medicare PIN