Provider Demographics
NPI:1336190644
Name:JACKSON, LINDA M (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 ELK AVE S
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3051
Mailing Address - Country:US
Mailing Address - Phone:931-433-2551
Mailing Address - Fax:931-433-1142
Practice Address - Street 1:207 ELK AVE S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3051
Practice Address - Country:US
Practice Address - Phone:931-433-2551
Practice Address - Fax:931-433-1142
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3338656Medicaid
TN3338656Medicaid
TN1336190644Medicare NSC
3338656Medicare PIN