Provider Demographics
NPI:1609952241
Name:OWENS, JACK D (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:OWENS
Suffix:
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7320
Mailing Address - Fax:423-439-7343
Practice Address - Street 1:325 N STATE OF FRANKLIN RD
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6056
Practice Address - Country:US
Practice Address - Phone:423-439-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS167642080N0001X
TN428012080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ073340Medicaid
MS00121969Medicaid
MS0121969Medicaid