Basic Information
| Provider Information | |||||||||
| NPI: | 1801881891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383402231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319890001 | ||||||||
| FaxNumber: | 7319895151 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383402231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319890001 | ||||||||
| FaxNumber: | 7319895151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD0000034823 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3867610 | 05 | TN | MEDICAID | P00111567 | 01 | TN | RAILROAD MEDICARE | OTHER |