Provider Demographics
NPI:1376717587
Name:JERDEN, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:JERDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6660 BAINBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8312
Mailing Address - Country:US
Mailing Address - Phone:901-755-9563
Mailing Address - Fax:
Practice Address - Street 1:6660 BAINBRIDGE DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8312
Practice Address - Country:US
Practice Address - Phone:901-755-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 13474367500000X
TNRN 100682163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00636938OtherRAILROAD MEDICARE
1376717587OtherCHAMPUS/HUMANA TRICARE
MS08755263Medicaid
TN4190554OtherBLUE CROSS
TN1507185Medicaid
AR168414001Medicaid
TN3600317Medicare PIN