Provider Demographics
NPI:1861472532
Name:JACKSON, ROBERT C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
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:PO BOX 32569
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2569
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:9430 PARK WEST BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4200
Practice Address - Country:US
Practice Address - Phone:865-690-4861
Practice Address - Fax:865-560-8525
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8261207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3163995Medicaid
3163999Medicare PIN
TN0677340001Medicare NSC
TN3163995Medicaid