Provider Demographics
NPI:1982160628
Name:DAUGHERTY, JENNIFER GAIL (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GAIL
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2120
Mailing Address - Country:US
Mailing Address - Phone:865-376-3406
Mailing Address - Fax:
Practice Address - Street 1:820 W RACE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2120
Practice Address - Country:US
Practice Address - Phone:865-376-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000025171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ090611Medicaid