Provider Demographics
NPI:1154595767
Name:MARY JANE JAMIESON
Entity type:Organization
Organization Name:MARY JANE JAMIESON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMIESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-815-8991
Mailing Address - Street 1:1589 SPARTA ST STE 305
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1389
Mailing Address - Country:US
Mailing Address - Phone:931-815-8991
Mailing Address - Fax:931-815-8966
Practice Address - Street 1:1589 SPARTA ST STE 305
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1389
Practice Address - Country:US
Practice Address - Phone:931-815-8991
Practice Address - Fax:931-815-8966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000029552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG69924Medicare UPIN
TN3725214Medicare PIN