Basic Information
| Provider Information | |||||||||
| NPI: | 1104107507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RISEDEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 RAVEN GROVE WAY | ||||||||
| Address2: | APT 338 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379187077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657129191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 FORT SANDERS WEST BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652884232 | ||||||||
| FaxNumber: | 8652884231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16065 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 16065 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 460643559 | 05 | TN | MEDICAID |