Provider Demographics
NPI:1497297949
Name:JELLICO HEALTHCARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:JELLICO HEALTHCARE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-7252
Mailing Address - Street 1:188 HOSPITAL LN
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-4400
Mailing Address - Country:US
Mailing Address - Phone:423-784-7252
Mailing Address - Fax:
Practice Address - Street 1:188 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-7252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty