Provider Demographics
NPI:1336448588
Name:JAQUITH, BRADLEY PETERSON (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:PETERSON
Last Name:JAQUITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306556
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6556
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:1819 CLINCH AVE STE 100
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2435
Practice Address - Country:US
Practice Address - Phone:865-524-5365
Practice Address - Fax:865-524-5047
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54212207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024105Medicaid
TN103I207844Medicare PIN