Individual
MS. JANA BRIELLE LACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
118 BROWN AVE STE 103, CROSSVILLE, TN 38555-7740
(931) 484-8861
(865) 374-2116
Mailing address
84 EDWARDS RD, CROSSVILLE, TN 38571-0599
(931) 787-8307
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Q078071
—
TN
Enumeration date
04/01/2022
Last updated
10/19/2022
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