Provider Demographics
NPI:1760949861
Name:PUCKETT, JESSICA (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HILLDALE LN
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-0368
Mailing Address - Country:US
Mailing Address - Phone:901-641-6830
Mailing Address - Fax:
Practice Address - Street 1:1314 PEABODY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3500
Practice Address - Country:US
Practice Address - Phone:901-321-5803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACU0000000145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNACU0000000145OtherTENNESSEE MEDICAL BOARD LICENSE