Provider Demographics
NPI:1972228054
Name:DEPEW, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:DEPEW
Suffix:
Gender:F
Credentials:
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 280
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-0280
Mailing Address - Country:US
Mailing Address - Phone:423-465-7388
Mailing Address - Fax:
Practice Address - Street 1:1224 GAY ST
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-4720
Practice Address - Country:US
Practice Address - Phone:865-397-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist