Provider Demographics
NPI:1407262603
Name:HAYWORTH, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HAYWORTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:HAYWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:208 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3910
Mailing Address - Country:US
Mailing Address - Phone:423-557-7278
Mailing Address - Fax:
Practice Address - Street 1:113 E UNAKA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4085
Practice Address - Country:US
Practice Address - Phone:423-928-9394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACU0000000152171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist