Provider Demographics
NPI:1417219189
Name:WELLFIT MEDICINE AND NUTRITION JACKSON, PLLC
Entity Type:Organization
Organization Name:WELLFIT MEDICINE AND NUTRITION JACKSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-300-3372
Mailing Address - Street 1:101 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2318
Mailing Address - Country:US
Mailing Address - Phone:731-300-3372
Mailing Address - Fax:731-300-3374
Practice Address - Street 1:101 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2318
Practice Address - Country:US
Practice Address - Phone:731-300-3372
Practice Address - Fax:731-300-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty