Provider Demographics
NPI:1659771350
Name:RONNIE L. JACKSON MD
Entity Type:Organization
Organization Name:RONNIE L. JACKSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-382-1037
Mailing Address - Street 1:496 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3972
Mailing Address - Country:US
Mailing Address - Phone:615-382-1037
Mailing Address - Fax:615-382-0990
Practice Address - Street 1:496 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3972
Practice Address - Country:US
Practice Address - Phone:615-382-1037
Practice Address - Fax:615-382-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD020868174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty