Provider Demographics
NPI:1043561608
Name:JACKSON, JENNIFER L (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3549
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0549
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:423-624-6355
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:423-624-6355
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16918367500000X
TNRN147906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4335469OtherBC BS OF TN
TN1530475Medicaid
P01124805OtherRAILROAD MEDICARE
TN43I8137Medicare PIN