Provider Demographics
NPI:1386678191
Name:JACKSON, CHAD MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2563
Mailing Address - Country:US
Mailing Address - Phone:615-893-1600
Mailing Address - Fax:615-225-6887
Practice Address - Street 1:1747 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2563
Practice Address - Country:US
Practice Address - Phone:615-893-1600
Practice Address - Fax:615-225-6887
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41238174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI53955Medicare UPIN
33386651Medicare PIN