Provider Demographics
NPI:1790552255
Name:DAVENPORT, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 PAUL DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-5229
Mailing Address - Country:US
Mailing Address - Phone:423-312-4687
Mailing Address - Fax:
Practice Address - Street 1:1820 PAUL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5229
Practice Address - Country:US
Practice Address - Phone:423-312-4687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000000729101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty