Provider Demographics
NPI:1801015821
Name:JACKSON, TINA LOUISE (MD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 W TYRONE RD RM 714
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6517
Mailing Address - Country:US
Mailing Address - Phone:865-482-1076
Mailing Address - Fax:
Practice Address - Street 1:224 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-4163
Practice Address - Country:US
Practice Address - Phone:423-346-6221
Practice Address - Fax:423-346-3447
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN612072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry