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Organization
FAMILY CLINIC AT THE LAKE PLLC
Active
Organization
FAMILY CLINIC AT THE LAKE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLANIKOLE JACKSON NP (OWNER)
(901) 500-8629
Entity
Organization
Contact information
Practice address
1440 PICKWICK ST, SAVANNAH, TN 38372-3519
(731) 925-3354
(731) 438-3581
Mailing address
PO BOX 55, SAVANNAH, TN 38372-0055
(731) 925-3354
(731) 438-3581
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
NULL
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
Other
Enumeration date
06/09/2025
Last updated
06/09/2025
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