Provider Demographics
NPI:1578591731
Name:NEBLETT, JOHN WALLACE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALLACE
Last Name:NEBLETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WEST FOREST
Mailing Address - Street 2:STE. 200
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301
Mailing Address - Country:US
Mailing Address - Phone:731-541-9490
Mailing Address - Fax:731-541-9485
Practice Address - Street 1:700 WEST FOREST
Practice Address - Street 2:STE 200
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-541-9490
Practice Address - Fax:731-541-9485
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11356207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3003235Medicaid
TN4052872OtherBLUE CROSS BLUE SHIELD
4034740OtherAETNA
D74293Medicare UPIN
4034740OtherAETNA
TN3003235Medicare ID - Type Unspecified