Organization
FAMILY CLINIC AT THE LAKE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLANIKOLE JACKSON NP (OWNER)
(731) 689-4357
Entity
Organization
Contact information
Practice address
11268 HIGHWAY 57, COUNCE, TN 38326-3802
(731) 689-4357
Mailing address
PO BOX 140, PICKWICK DAM, TN 38365-0140
(731) 689-4357
(731) 689-1050
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
06/28/2019
Last updated
10/14/2019
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