Provider Demographics
NPI:1174239677
Name:MCCOY, JESSE L
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:L
Last Name:MCCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 DUNLOP LN STE 106
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5296
Mailing Address - Country:US
Mailing Address - Phone:931-272-2431
Mailing Address - Fax:
Practice Address - Street 1:495 DUNLOP LN STE 106
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5296
Practice Address - Country:US
Practice Address - Phone:931-272-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68923164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse