Provider Demographics
NPI:1275894347
Name:JUSTICE, JACKIE LEANNE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEANNE
Last Name:JUSTICE
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 1:301 MCGHEE ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-6811
Mailing Address - Country:US
Mailing Address - Phone:865-983-4582
Mailing Address - Fax:865-983-4574
Practice Address - Street 1:301 MCGHEE ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-6811
Practice Address - Country:US
Practice Address - Phone:865-983-4582
Practice Address - Fax:865-983-4574
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN93903376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide