Provider Demographics
NPI:1720653629
Name:JACKSON, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
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 1:171 NOAH LN
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-5575
Mailing Address - Country:US
Mailing Address - Phone:423-912-5097
Mailing Address - Fax:
Practice Address - Street 1:171 NOAH LN
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-5575
Practice Address - Country:US
Practice Address - Phone:423-912-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN102279163WC0400X, 163WC1500X, 163WH1000X, 163WM0705X, 163WN1003X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Single Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty
No163WN1003XNursing Service ProvidersRegistered NurseNutrition SupportGroup - Single Specialty