NPIMap

Organization Active NPI

Family Clinic at the Lake PLLC

  • Rural Health Clinic/Center
  • Savannah, TN
National Provider Identifier
1295620557
Registry record updated Jun 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
FAMILY CLINIC AT THE LAKE PLLC
Practice address
1440 Pickwick St
Savannah, TN 38372-3519
Phone
(731) 925-3354
Fax
(731) 438-3581
NPI assigned
Jun 9, 2025
Last updated
Jun 9, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ellanikole Jackson, NPNPI 1932676194
Title
Owner
Phone
(901) 500-8629

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Family Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

1440 Pickwick St
Savannah, TN 38372-3519

Mailing address

PO Box 55
Savannah, TN 38372-0055
Phone (731) 925-3354

National Provider Directory

National Provider Directory
Tax ID family
Family Clinic at the Lake2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1749427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749427200000",
    "number": "1295620557",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 55",
            "city": "SAVANNAH",
            "state": "TN",
            "postal_code": "383720055",
            "telephone_number": "731-925-3354",
            "fax_number": "731-438-3581"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1440 PICKWICK ST",
            "city": "SAVANNAH",
            "state": "TN",
            "postal_code": "383723519",
            "telephone_number": "731-925-3354",
            "fax_number": "731-438-3581"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY CLINIC AT THE LAKE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-06-09",
        "last_updated": "2025-06-09",
        "certification_date": "2025-06-09",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "ELLANIKOLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "901-500-8629",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Savannah, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.