Provider Demographics
NPI:1356419055
Name:JACKSON, ELBERT E (DDS)
Entity type:Individual
Prefix:
First Name:ELBERT
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 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
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS24741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN557446OtherUCCI