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Organization
JELLICO WELLNESS AND CONVENIENT CARE CLINIC, LLC
Active
Organization
JELLICO WELLNESS AND CONVENIENT CARE CLINIC, LLC
Active
Other names
Jellico Wellness Behavioral Health
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE ASANTE FAMILY NURSE PRACTIT (FNP/PRESIDENT)
(615) 335-3430
Entity
Organization
Contact information
Practice address
1811 5TH ST, JELLICO, TN 37762-4629
(615) 335-3430
Mailing address
1811 5TH ST, JELLICO, TN 37762-4629
(423) 455-3032
(423) 455-3042
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
NULL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
363LP2300X
Primary Care Nurse Practitioner
14174
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1031508098
MEDICARE
TN
05
—
1527342
—
TN
Enumeration date
03/21/2018
Last updated
09/05/2024
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