Organization
WIREGRASS CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER L JACKSON (SR DIR PROV ENROLLMENT & ONBOARDING)
(615) 465-3334
Entity
Organization
Contact information
Practice address
4300 W MAIN ST STE 14, DOTHAN, AL 36305-1311
(334) 944-7015
(334) 944-7019
Mailing address
PO BOX 689022, FRANKLIN, TN 37068-9022
(615) 465-7230
(615) 628-6877
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Enumeration date
09/30/2021
Last updated
10/08/2021
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