Provider Demographics
NPI:1235224916
Name:JACKSON, TENNYE R (MD)
Entity Type:Individual
Prefix:DR
First Name:TENNYE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 KNIGHT ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3035
Mailing Address - Country:US
Mailing Address - Phone:901-753-7154
Mailing Address - Fax:901-755-9035
Practice Address - Street 1:3960 KNIGHT ARNOLD RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3035
Practice Address - Country:US
Practice Address - Phone:901-753-7154
Practice Address - Fax:901-755-9035
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN27165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3097061Medicare ID - Type Unspecified