Provider Demographics
NPI:1871652172
Name:ELBERT E JACKSON, DDS, PC
Entity Type:Organization
Organization Name:ELBERT E JACKSON, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-859-1881
Mailing Address - Street 1:200 GLEAVES ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2154
Mailing Address - Country:US
Mailing Address - Phone:615-859-1881
Mailing Address - Fax:615-865-7723
Practice Address - Street 1:200 GLEAVES ST
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2154
Practice Address - Country:US
Practice Address - Phone:615-859-1881
Practice Address - Fax:615-865-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS24741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty