Basic Information
| Provider Information | |||||||||
| NPI: | 1023730298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFITH | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | MARIE CECILIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 BOWMAN CIRCLE DR NE | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373125016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236508763 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6110 SHALLOWFORD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2022 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 230136 | TN | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 32373 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.