Provider Demographics
NPI:1790425080
Name:LACK, JANA BRIELLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:BRIELLE
Last Name:LACK
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 1:84 EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38571-0599
Mailing Address - Country:US
Mailing Address - Phone:931-787-8307
Mailing Address - Fax:
Practice Address - Street 1:118 BROWN AVE STE 103
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-7740
Practice Address - Country:US
Practice Address - Phone:931-484-8861
Practice Address - Fax:865-374-2116
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ078071Medicaid