Provider Demographics
NPI:1194914697
Name:JACKSON OB-GYN ASSOCIATES, P.C.
Entity type:Organization
Organization Name:JACKSON OB-GYN ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:GOOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-427-9601
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0636
Mailing Address - Country:US
Mailing Address - Phone:731-427-9601
Mailing Address - Fax:731-427-4334
Practice Address - Street 1:8 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3947
Practice Address - Country:US
Practice Address - Phone:731-427-9601
Practice Address - Fax:731-427-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3710915Medicare PIN