Provider Demographics
NPI:1306842356
Name:JACKSON, BRIAN D (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:1215 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3531
Practice Address - Country:US
Practice Address - Phone:615-220-8788
Practice Address - Fax:615-220-8688
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN436213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN480034585OtherRAILROAD MEDICARE
TN4042682OtherBLUE CROSS
TNDC1001OtherRAILROAD MEDICARE GROUP
TN3352132Medicaid
TN4599510001Medicare NSC
TN4599510002Medicare NSC
TNU35034Medicare UPIN
TN4042682OtherBLUE CROSS