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
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
44D2112604
CLIA
TN
Enumeration date
06/09/2025
Last updated
06/09/2025
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