Provider Demographics
NPI:1952344723
Name:JEANSONNE, GREGORY EDMUND (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EDMUND
Last Name:JEANSONNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 JOHN B DENNIS HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-245-3161
Mailing Address - Fax:423-857-8129
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4044
Practice Address - Country:US
Practice Address - Phone:804-483-6305
Practice Address - Fax:804-483-6159
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036150676207X00000X
WI424-320207X00000X
TN40154207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1952344723Medicaid
TNMD040154OtherLICENSE
TN3817403Medicaid
LAMD025630OtherLICENSE
TNMD040154OtherLICENSE
VAVV1184B132Medicare PIN
TN6682290001Medicare NSC