Basic Information
| Provider Information | |||||||||
| NPI: | 1134154081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLINGSWORTH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | STE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315843151 | ||||||||
| FaxNumber: | 7315843168 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315843151 | ||||||||
| FaxNumber: | 7315843168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13614 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00271743 | 01 | RR MEDICARE | OTHER | 3002034 | 05 | TN | MEDICAID | 3002037 | 05 | TN | MEDICAID | 4114640 | 01 | BCBS | OTHER |