Provider Demographics
NPI:1962641530
Name:KING, JENNIFER P (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:229 INTERSTATE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2709
Mailing Address - Country:US
Mailing Address - Phone:931-210-5577
Mailing Address - Fax:931-210-5575
Practice Address - Street 1:100 S DUNCAN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-3009
Practice Address - Country:US
Practice Address - Phone:931-879-5864
Practice Address - Fax:931-879-3903
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1695363A00000X
TN001695363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1695OtherTN STATE LICENSE