Provider Demographics
NPI:1205059995
Name:JACKSON, CHERYL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 POPLAR AVE
Mailing Address - Street 2:STE. 514
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4426
Mailing Address - Country:US
Mailing Address - Phone:901-763-3601
Mailing Address - Fax:901-763-3602
Practice Address - Street 1:4646 POPLAR AVE
Practice Address - Street 2:STE. 514
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4426
Practice Address - Country:US
Practice Address - Phone:901-763-3601
Practice Address - Fax:901-763-3602
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000007109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist