Provider Demographics
NPI:1467592774
Name:FENTRESS FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:FENTRESS FAMILY PRACTICE PLLC
Other - Org Name:FENTRESS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CLAPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-879-4645
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38556-0965
Mailing Address - Country:US
Mailing Address - Phone:931-879-4645
Mailing Address - Fax:931-879-2606
Practice Address - Street 1:101 S DUNCAN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-9999
Practice Address - Country:US
Practice Address - Phone:931-879-4645
Practice Address - Fax:931-879-2606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3714535Medicaid
TN3714535Medicare ID - Type Unspecified