Basic Information
| Provider Information | |||||||||
| NPI: | 1184169658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JARRETT | ||||||||
| FirstName: | WANDA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 STOUT DRIVE | ||||||||
| Address2: | BOX 70403 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394515 | ||||||||
| FaxNumber: | 4234395780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S SHADY ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237271150 | ||||||||
| FaxNumber: | 4237271151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 363LW0102X | 21429 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 21429 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3714470 | 01 | TN | GROUP MEDICARE | OTHER | 21429 | 01 | TN | LICENSE | OTHER |