Provider Demographics
NPI:1386836252
Name:BRIAN D. JACKSON, DPM, LLC
Entity Type:Organization
Organization Name:BRIAN D. JACKSON, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:931-380-0353
Mailing Address - Street 1:1215 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3531
Mailing Address - Country:US
Mailing Address - Phone:931-380-0353
Mailing Address - Fax:
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:931-380-0353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN436213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDC1001OtherRAILROAD MEDICARE GROUP
3414014OtherCIGNA
3352132OtherMEDICARE GROUP PIN
2740069OtherUNITED HEALTHCARE
4042682OtherBLUE CROSS OF TN
480034585OtherRAILROAD MEDICARE
3352133Medicare PIN
3352132OtherMEDICARE GROUP PIN