Provider Demographics
NPI:1104834555
Name:JACKSON, CASEY GORDON (MD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:GORDON
Last Name:JACKSON
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 1:877 JEFFERSON AVE
Mailing Address - Street 2:5TH FLOOR ADAMS PAVILION
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-515-4529
Mailing Address - Fax:901-515-4599
Practice Address - Street 1:4095 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-8339
Practice Address - Country:US
Practice Address - Phone:901-515-5000
Practice Address - Fax:901-375-0982
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine