Basic Information
| Provider Information | |||||||||
| NPI: | 1972632362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STINNES | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2907 MCVAY TRAIL DR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381198762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017376820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1265 UNION AVE | ||||||||
| Address2: | 1 SHERARD | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015169183 | ||||||||
| FaxNumber: | 9015168943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2007 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 118029 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3640121 | 05 | TN | MEDICAID |