Provider Demographics
NPI:1669115770
Name:JACKSON, SCOTT CHRISTIAN
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHRISTIAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17649 ROCKWOOD ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-4035
Mailing Address - Country:US
Mailing Address - Phone:636-236-3714
Mailing Address - Fax:
Practice Address - Street 1:5180 PARK AVE STE 210
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3530
Practice Address - Country:US
Practice Address - Phone:901-763-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN122451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program