Provider Demographics
NPI:1710913298
Name:AMBURN, JENNIFER F (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:F
Last Name:AMBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1382
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:200 FORT SANDERS WEST BLVD STE 304
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3360
Practice Address - Country:US
Practice Address - Phone:865-531-8848
Practice Address - Fax:833-908-2105
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ003822Medicaid
TN103I978763Medicare PIN
TNP00348129OtherRR MEDICARE
TN3706639Medicare ID - Type UnspecifiedLEGACY GROUP