Provider Demographics
NPI:1063113660
Name:RIVERS, LAJACQUA (NP)
Entity type:Individual
Prefix:
First Name:LAJACQUA
Middle Name:
Last Name:RIVERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RUSHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2145
Mailing Address - Country:US
Mailing Address - Phone:731-326-0516
Mailing Address - Fax:
Practice Address - Street 1:2634 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-1534
Practice Address - Country:US
Practice Address - Phone:731-324-1526
Practice Address - Fax:731-324-1534
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000242729163W00000X
TN37150363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse