Provider Demographics
NPI:1891732236
Name:TUBERTY, JESSICA B (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:TUBERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3734
Mailing Address - Country:US
Mailing Address - Phone:423-547-9400
Mailing Address - Fax:423-547-9401
Practice Address - Street 1:1937 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3734
Practice Address - Country:US
Practice Address - Phone:423-547-9400
Practice Address - Fax:423-547-9401
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD40221208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4115429OtherBCBS
TN3336052Medicaid
TNTN0103OtherJOHN DEERE
TN3336052Medicare ID - Type Unspecified
I46796Medicare UPIN