Provider Demographics
NPI:1578237871
Name:JACKSON, BRUCE JR
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-373-7116
Practice Address - Street 1:1272 GARRISON DR STE 303
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-0053
Practice Address - Country:US
Practice Address - Phone:615-849-9358
Practice Address - Fax:615-849-9360
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225100000X
TN13754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist