Provider Demographics
NPI:1649378464
Name:JACKSON, JASON COLE (PA-C, DC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:COLE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 DINAH SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1107
Mailing Address - Country:US
Mailing Address - Phone:931-967-6669
Mailing Address - Fax:931-967-6606
Practice Address - Street 1:1211 DINAH SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-1107
Practice Address - Country:US
Practice Address - Phone:931-967-6669
Practice Address - Fax:931-967-6606
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002010111N00000X
TN2187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4117134OtherTN BC/BS
TN4117134OtherTN BC/BS
TN3973375Medicare ID - Type UnspecifiedTN MEDICARE