Provider Demographics
NPI:1922597087
Name:CHANDLER, JAKE MAJURE (RN)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:MAJURE
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4246
Mailing Address - Country:US
Mailing Address - Phone:601-562-5934
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-818-2160
Practice Address - Fax:901-682-9443
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24813367500000X
MS894584163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44-0048Medicaid