Basic Information
Provider Information | |||||||||
NPI: | 1467457341 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COMPTON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376620009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238572066 | ||||||||
FaxNumber: | 4233903339 | ||||||||
Practice Location | |||||||||
Address1: | 4848 FORT HENRY DR | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376633347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238572066 | ||||||||
FaxNumber: | 4238572066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 11/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0000000275 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 5645956 | 01 | VA | VA MEDICAID | OTHER | 830342546 | 01 | TN | JOHN DEERE | OTHER | 103I977037 | 05 | TN |   | MEDICAID | 080194591 | 01 | TN | RAILROAD MEDICARE | OTHER | 246269 | 01 | VA | ANTHEM BCBS VA | OTHER | 4059748 | 01 | TN | BCBS TN | OTHER |