Provider Demographics
NPI:1952834558
Name:WHITEHEAD, JACK MOORE (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MOORE
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SEABOARD LN STE 201
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3040
Mailing Address - Country:US
Mailing Address - Phone:152-611-2106
Mailing Address - Fax:
Practice Address - Street 1:95 SEABOARD LN STE 201
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3040
Practice Address - Country:US
Practice Address - Phone:615-261-1210
Practice Address - Fax:615-261-1222
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN60997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program