Basic Information
Provider Information | |||||||||
NPI: | 1104309681 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOTSON | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: | CAROL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CROCKETT | ||||||||
OtherFirstName: | JACQUELINE | ||||||||
OtherMiddleName: | CAROL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1275 DICK LONAS RD | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379091382 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655844747 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 641 MIDDLE CREEK RD | ||||||||
Address2: |   | ||||||||
City: | SEVIERVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378625014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8654280583 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2018 | ||||||||
LastUpdateDate: | 07/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN176793 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | APN24531 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.