Provider Demographics
NPI:1417906827
Name:JACKSON, TREENA W (FNP, MSN)
Entity Type:Individual
Prefix:MRS
First Name:TREENA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-6286
Mailing Address - Fax:901-545-8122
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-515-3500
Practice Address - Fax:901-515-3509
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000101380363L00000X
TNAPN7037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3928585Medicare ID - Type Unspecified
TNQ15670Medicare UPIN