Provider Demographics
NPI:1912902396
Name:JAMIESON, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:JAMIESON
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 1:1589 SPARTA ST STE 305
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1389
Mailing Address - Country:US
Mailing Address - Phone:931-815-8991
Mailing Address - Fax:931-815-8966
Practice Address - Street 1:1589 SPARTA ST
Practice Address - Street 2:STE 305
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1389
Practice Address - Country:US
Practice Address - Phone:931-815-8991
Practice Address - Fax:931-815-8966
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2008-04-15
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
TNMD0000029552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG69924Medicare UPIN
TN3725214Medicare PIN