1386836252 NPI number — BRIAN D. JACKSON, DPM, LLC

Table of content: (NPI 1386836252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386836252 NPI number — BRIAN D. JACKSON, DPM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN D. JACKSON, DPM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386836252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 HATCHER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38401-3531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-380-0353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 HATCHER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38401-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-380-0353
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
931-380-0353

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  436 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC1001 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3414014 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3352132 . This is a "MEDICARE GROUP PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2740069 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4042682 . This is a "BLUE CROSS OF TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480034585 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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