Basic Information
| Provider Information | |||||||||
| NPI: | 1336448588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAQUITH | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | PETERSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9118 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554809118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656947725 | ||||||||
| FaxNumber: | 8656738007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 CLINCH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655245365 | ||||||||
| FaxNumber: | 8655245047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2011 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 54212 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 54212 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q024105 | 05 | TN | MEDICAID |