Provider Demographics
NPI:1588289649
Name:DROLL, JENNIFERLYN MCGORTY (DPM)
Entity type:Individual
Prefix:
First Name:JENNIFERLYN
Middle Name:MCGORTY
Last Name:DROLL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:MCGORTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:135 CHESAPEAKE LANE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:931-245-1920
Mailing Address - Fax:931-245-1928
Practice Address - Street 1:135 CHESAPEAKE LANE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3704
Practice Address - Country:US
Practice Address - Phone:931-245-1920
Practice Address - Fax:931-245-1928
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPL61170089390200000X
TN970213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2180476Medicaid