Provider Demographics
NPI:1972852341
Name:JTP ENTERPRISES, LLC
Entity Type:Organization
Organization Name:JTP ENTERPRISES, LLC
Other - Org Name:THE FAMILY CARE CLINIC OF SPARTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:PERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:931-707-7117
Mailing Address - Street 1:287 TURNTABLE RD.
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583
Mailing Address - Country:US
Mailing Address - Phone:931-738-2000
Mailing Address - Fax:888-337-7080
Practice Address - Street 1:287 TURNTABLE RD.
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583
Practice Address - Country:US
Practice Address - Phone:931-738-2000
Practice Address - Fax:888-337-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7811207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0448921Medicaid
TN1548460447OtherNPI
TN0448921Medicaid