Provider Demographics
NPI:1952504938
Name:SULLIVAN, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SULLIVAN
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:PO BOX 1000
Mailing Address - Street 2:DEPT # 457
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-448-2918
Mailing Address - Fax:901-266-6427
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-448-2918
Practice Address - Fax:901-266-6427
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51617208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04125350Medicaid
TN6021477OtherBCBS
TNQ008106Medicaid
AR205257001Medicaid
TN103I336840Medicare PIN