Provider Demographics
NPI:1669941290
Name:JACKSON, BRETT (FNP)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-0326
Mailing Address - Country:US
Mailing Address - Phone:931-563-7464
Mailing Address - Fax:931-563-7401
Practice Address - Street 1:215 S ANDERSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3735
Practice Address - Country:US
Practice Address - Phone:931-563-7464
Practice Address - Fax:931-563-7401
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25168363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily