Provider Demographics
NPI:1508042276
Name:FARRIS, JACQUELINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:FARRIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4250 FARONIA RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6250
Mailing Address - Country:US
Mailing Address - Phone:901-236-7707
Mailing Address - Fax:901-236-7865
Practice Address - Street 1:4250 FARONIA RD STE 2A
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6250
Practice Address - Country:US
Practice Address - Phone:901-236-7707
Practice Address - Fax:901-236-7865
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-12
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000015191363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics