Provider Demographics
NPI:1487620274
Name:TAYLOR, JENNIFER R (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 313
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-3780
Practice Address - Fax:276-258-3776
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166234363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1487620274Medicaid
TNQ004987Medicaid
P01214685OtherRR MEDICARE
VA231160700OtherDOL
VA231160700OtherDOL
VA1487620274Medicaid
P01214685OtherRR MEDICARE
VA0086832W82Medicare PIN
VAP00258738Medicare PIN
VA011695A49Medicare PIN