Provider Demographics
NPI:1437135084
Name:TSAO, JACK W (MD, DPHIL)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:TSAO
Suffix:
Gender:M
Credentials:MD, DPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 MONROE AVE STE 226
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4901
Mailing Address - Country:US
Mailing Address - Phone:901-448-7674
Mailing Address - Fax:901-448-7440
Practice Address - Street 1:1331 UNION AVE STE 1145
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7509
Practice Address - Country:US
Practice Address - Phone:901-448-7674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN511452084B0040X, 2084N0400X
NY3102452084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031283Medicaid
AR226224001Medicaid
MO1437135084Medicaid
MS03882085Medicaid