Provider Demographics
NPI:1356810246
Name:JENNEWINE, EMILY (MSN, CPNP, PC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JENNEWINE
Suffix:
Gender:
Credentials:MSN, CPNP, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 MOUNT MORIAH ROAD EXT STE 4
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-2665
Mailing Address - Country:US
Mailing Address - Phone:901-531-8800
Mailing Address - Fax:
Practice Address - Street 1:6063 MOUNT MORIAH ROAD EXT STE 4
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-2665
Practice Address - Country:US
Practice Address - Phone:901-531-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193105363LP0200X
TN0000027454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA540886561OtherGROUP TAX ID NUMBER