Provider Demographics
NPI:1932172624
Name:JACOBS, GORDON JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:JACKSON
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
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 271
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37111-0271
Mailing Address - Country:US
Mailing Address - Phone:931-507-5000
Mailing Address - Fax:931-507-5550
Practice Address - Street 1:485 N CHANCERY ST
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2049
Practice Address - Country:US
Practice Address - Phone:931-507-5000
Practice Address - Fax:931-507-5550
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD010995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3164944Medicaid
3164944Medicare ID - Type Unspecified
B03084Medicare UPIN