Provider Demographics
NPI:1649288051
Name:JACKSON, BECKY L (MD)
Entity type:Individual
Prefix:DR
First Name:BECKY
Middle Name:L
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 1:8920 EXECUTIVE PARK DR
Mailing Address - Street 2:F-100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4714
Mailing Address - Country:US
Mailing Address - Phone:865-670-6725
Mailing Address - Fax:
Practice Address - Street 1:8920 EXECUTIVE PARK DR
Practice Address - Street 2:F-100
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4714
Practice Address - Country:US
Practice Address - Phone:865-670-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNE12889Medicare UPIN