Provider Demographics
NPI:1689610628
Name:JACKSON, REBECCA T (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:10215 KINGSTON PIKE
Practice Address - Street 2:STE 100
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3222
Practice Address - Country:US
Practice Address - Phone:865-691-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110136878OtherRR MEDICARE PIN
TN3807952Medicaid
TN3807952Medicaid
TN110136878OtherRR MEDICARE PIN
TN3807953Medicare ID - Type UnspecifiedLEGACY PIN