Provider Demographics
NPI:1447972898
Name:JENNINGS, MALLORY LYNN (FNP)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LYNN
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MALLORY
Other - Middle Name:LYNN
Other - Last Name:KERKSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3628 CREST RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-4014
Mailing Address - Country:US
Mailing Address - Phone:423-367-1509
Mailing Address - Fax:
Practice Address - Street 1:2898 BOONES CREEK RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4975
Practice Address - Country:US
Practice Address - Phone:423-262-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily