Provider Demographics
NPI:1811286651
Name:HEALTHSOURCE OF JACKSON
Entity type:Organization
Organization Name:HEALTHSOURCE OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HEATHCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:731-661-0390
Mailing Address - Street 1:384 CARRIAGE HOUSE DR STE C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2268
Mailing Address - Country:US
Mailing Address - Phone:731-661-0390
Mailing Address - Fax:731-664-6697
Practice Address - Street 1:384 CARRIAGE HOUSE DR STE C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2268
Practice Address - Country:US
Practice Address - Phone:731-661-0390
Practice Address - Fax:731-664-6697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty