Provider Demographics
NPI:1124494513
Name:ROSE, JODI WATSON (NP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:WATSON
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2253 CHAMBLISS AVE NW STE 301
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3961
Mailing Address - Country:US
Mailing Address - Phone:423-476-5002
Mailing Address - Fax:423-339-4466
Practice Address - Street 1:2253 CHAMBLISS AVE NW STE 301
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3961
Practice Address - Country:US
Practice Address - Phone:423-476-5002
Practice Address - Fax:423-339-4466
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000020261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022271Medicaid