Provider Demographics
NPI:1245665868
Name:MOSS, JANTZEN (LPN)
Entity type:Individual
Prefix:
First Name:JANTZEN
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-660-7971
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:4039 HIGHLAND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3483
Practice Address - Country:US
Practice Address - Phone:731-723-1327
Practice Address - Fax:731-660-8739
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65174164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse