Provider Demographics
NPI:1760484372
Name:JACKSON, TERRENCE L JR (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:L
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8000 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-747-3630
Mailing Address - Fax:901-747-4039
Practice Address - Street 1:8000 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-747-3630
Practice Address - Fax:901-747-4039
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000033995207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH35754Medicare UPIN