Provider Demographics
NPI:1508369703
Name:JACK PETTIGREW PLLC
Entity Type:Organization
Organization Name:JACK PETTIGREW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIGREW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:731-432-9461
Mailing Address - Street 1:PO BOX 1452
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-1452
Mailing Address - Country:US
Mailing Address - Phone:731-432-9461
Mailing Address - Fax:
Practice Address - Street 1:514 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-3711
Practice Address - Country:US
Practice Address - Phone:731-432-9461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty