Basic Information
| Provider Information | |||||||||
| NPI: | 1154659589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCLENDON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 E 3RD ST | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237785630 | ||||||||
| FaxNumber: | 4237783146 | ||||||||
| Practice Location | |||||||||
| Address1: | 979 E 3RD ST | ||||||||
| Address2: | SUITE C430 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237784900 | ||||||||
| FaxNumber: | 4237784901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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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 | 363AM0700X | 005734 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 2801 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2801 | 01 | TN | TENNESSEE STATE LICENSE | OTHER | 005734 | 01 | GA | GA STATE LICENSE | OTHER | 1089225 | 01 | NCCPA IDENTIFICATION NUMBER | OTHER | Q014360 | 05 | TN | MEDICAID |