Provider Demographics
NPI:1891053526
Name:JACKSON, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 ORVILLE BATES LN
Mailing Address - Street 2:
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330-4278
Mailing Address - Country:US
Mailing Address - Phone:931-222-0801
Mailing Address - Fax:
Practice Address - Street 1:240 ORVILLE BATES LN
Practice Address - Street 2:
Practice Address - City:ESTILL SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37330-4278
Practice Address - Country:US
Practice Address - Phone:931-222-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health