Provider Demographics
NPI:1942263793
Name:JACKSON, CHARLES LEE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
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 1:725 GLENWOOD DR
Mailing Address - Street 2:STE E790
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1178
Mailing Address - Country:US
Mailing Address - Phone:423-495-3068
Mailing Address - Fax:423-495-3022
Practice Address - Street 1:725 GLENWOOD DR
Practice Address - Street 2:STE E790
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1178
Practice Address - Country:US
Practice Address - Phone:423-495-3068
Practice Address - Fax:423-495-3022
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053658208800000X
TN41776208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044337900Medicaid
TN1507399Medicaid
FLD51882Medicare UPIN
FL044337900Medicaid
TN3001827Medicare PIN