Basic Information
| Provider Information | |||||||||
| NPI: | 1326031071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERNIGAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 OAK RIDGE TPKE | ||||||||
| Address2: | SUITE C-100 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654238822 | ||||||||
| FaxNumber: | 8654824400 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 OAK RIDGE TPKE | ||||||||
| Address2: | SUITE C-100 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654238822 | ||||||||
| FaxNumber: | 8654824400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | 9533 | TN | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 64744444 | 05 | TN | MEDICAID | 3171072 | 05 | TN | MEDICAID |