Provider Demographics
NPI:1386638203
Name:GREENE-GUNTER, JACKIE LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:GREENE-GUNTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 TANNER WAY
Mailing Address - Street 2:STE 120
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748
Mailing Address - Country:US
Mailing Address - Phone:865-882-1535
Mailing Address - Fax:865-882-9497
Practice Address - Street 1:1855 TANNER WAY
Practice Address - Street 2:STE 120
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748
Practice Address - Country:US
Practice Address - Phone:865-882-1535
Practice Address - Fax:865-882-9497
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0888152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595618Medicaid
T61259Medicare UPIN