Provider Demographics
NPI:1104804764
Name:JACK, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:JACK
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 682749
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-2749
Mailing Address - Country:US
Mailing Address - Phone:615-807-4020
Mailing Address - Fax:615-807-4022
Practice Address - Street 1:2010 QUAIL HOLLOW CIR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5967
Practice Address - Country:US
Practice Address - Phone:615-807-4020
Practice Address - Fax:615-807-4022
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD131412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3025734Medicaid
TN35759OtherBCBS
TN1588204OtherUNITED HEALTHCARE
TN260010800OtherRAILROAD MEDICARE
TN260010800OtherRAILROAD MEDICARE