Provider Demographics
NPI:1952994626
Name:JACKSON, JENNIFER LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 HAYES ST
Mailing Address - Street 2:STE 200
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2689
Mailing Address - Country:US
Mailing Address - Phone:615-324-1600
Mailing Address - Fax:615-324-1661
Practice Address - Street 1:2004 HAYES ST STE 200
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2689
Practice Address - Country:US
Practice Address - Phone:615-324-1600
Practice Address - Fax:615-324-1661
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-14
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty