Provider Demographics
NPI:1982432316
Name:JACK, AMANDA G
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:JACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BELINDA PKWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-4390
Mailing Address - Country:US
Mailing Address - Phone:615-573-7546
Mailing Address - Fax:
Practice Address - Street 1:77 BELINDA PKWY
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-4390
Practice Address - Country:US
Practice Address - Phone:615-391-4394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant