Provider Demographics
NPI:1538308432
Name:NURTURED LIVING OF CHATTANOOGA
Entity Type:Organization
Organization Name:NURTURED LIVING OF CHATTANOOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED PRACTICAL N
Authorized Official - Phone:423-304-1847
Mailing Address - Street 1:1301 WOODMORE LANE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411
Mailing Address - Country:US
Mailing Address - Phone:423-624-2060
Mailing Address - Fax:423-624-2055
Practice Address - Street 1:1301 WOODMORE LANE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411
Practice Address - Country:US
Practice Address - Phone:423-624-2060
Practice Address - Fax:423-624-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1438-058-9179171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445217Medicaid