Basic Information
| Provider Information | |||||||||
| NPI: | 1831331826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | JEFFERSON | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 681478 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370681478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155916590 | ||||||||
| FaxNumber: | 6155916601 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 WHITE BRIDGE RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372051499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153669935 | ||||||||
| FaxNumber: | 6153569489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 04/06/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8282 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0446631 | 05 | TN | MEDICAID |