Provider Demographics
NPI:1811237001
Name:JACKSON, KENNETH S (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:123 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRUCETON
Practice Address - State:TN
Practice Address - Zip Code:38317-1819
Practice Address - Country:US
Practice Address - Phone:731-586-4800
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherGROUP MEDICAID
TN3380640OtherGROUP MEDICARE
TN10350I2435OtherMEDICARE PTAN
TNQ001235Medicaid