Provider Demographics
NPI:1639190051
Name:JACKSON, KELLI JOHNSON
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JOHNSON
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 1:1221 BUCKHEAD DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7878
Mailing Address - Country:US
Mailing Address - Phone:615-837-8422
Mailing Address - Fax:
Practice Address - Street 1:6814 CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-4206
Practice Address - Country:US
Practice Address - Phone:615-352-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3940088Medicaid
TNP00265658OtherRAILROAD MEDICARE PROV #
TN4134928OtherBCBS & TNCARE SELECT #
TN4134928OtherBCBS & TNCARE SELECT #
TNP00265658OtherRAILROAD MEDICARE PROV #