Provider Demographics
NPI:1326650789
Name:PUTNAM, JENNIFER R (MSN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:MSN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3946
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-422-0475
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNINPROCESS363L00000X
TN28168363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner