Provider Demographics
NPI:1326566860
Name:JACKSON, JAMIE LYNN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HENRY LN
Mailing Address - Street 2:
Mailing Address - City:LOOKOUT MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30750-2710
Mailing Address - Country:US
Mailing Address - Phone:303-328-5869
Mailing Address - Fax:
Practice Address - Street 1:6245 VANCE RD STE 109
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4836
Practice Address - Country:US
Practice Address - Phone:303-328-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN306171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN306OtherACUPUNCTURE LICENSE
TN171100000XMedicaid