Provider Demographics
NPI:1932808144
Name:JACKSON, ANDREW (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
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 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:615-591-6590
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:1700 W MARKET ST STE F&G
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1653
Practice Address - Country:US
Practice Address - Phone:731-658-2206
Practice Address - Fax:731-659-2061
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029723Medicaid