Provider Demographics
NPI:1972702819
Name:ELLIS, JENNIFER LOWE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOWE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 CARRIGAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8200
Mailing Address - Country:US
Mailing Address - Phone:931-551-4100
Mailing Address - Fax:931-551-8010
Practice Address - Street 1:1539 ASHLAND CITY RD STE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6416
Practice Address - Country:US
Practice Address - Phone:931-551-4100
Practice Address - Fax:931-551-8710
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN280602083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH32928Medicare UPIN