Provider Demographics
NPI:1750651832
Name:TRUECARE PHYSICIANS CLINIC OF JACKSON PLLC
Entity Type:Organization
Organization Name:TRUECARE PHYSICIANS CLINIC OF JACKSON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-616-6881
Mailing Address - Street 1:2796 N HIGHLAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1844
Mailing Address - Country:US
Mailing Address - Phone:731-616-6881
Mailing Address - Fax:731-736-1909
Practice Address - Street 1:11 WYNDCHASE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-7529
Practice Address - Country:US
Practice Address - Phone:731-616-6881
Practice Address - Fax:731-736-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36105207Q00000X
TN35452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G702924Medicare PIN
TNPENDINGMedicare PIN