Provider Demographics
NPI:1952805319
Name:JELLICO WELLNESS AND CONVENIENT CARE CLINIC, LLC
Entity type:Organization
Organization Name:JELLICO WELLNESS AND CONVENIENT CARE CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FNP/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASANTE
Authorized Official - Suffix:
Authorized Official - Credentials:FAMILY NURSE PRACTIT
Authorized Official - Phone:615-335-3430
Mailing Address - Street 1:1811 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-4629
Mailing Address - Country:US
Mailing Address - Phone:423-455-3032
Mailing Address - Fax:423-455-3042
Practice Address - Street 1:1811 5TH ST
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4629
Practice Address - Country:US
Practice Address - Phone:615-335-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LF0000X, 363LP0808X
TN14174363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527342Medicaid
TN1031508098OtherMEDICARE