Provider Demographics
NPI:1851063432
Name:WIREGRASS CLINIC LLC
Entity Type:Organization
Organization Name:WIREGRASS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7230
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:4300 W MAIN ST STE 405
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1086
Practice Address - Country:US
Practice Address - Phone:334-944-7073
Practice Address - Fax:334-944-7058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WIREGRASS CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty