Provider Demographics
NPI:1285375543
Name:JACKSON, PAUL ANTHONY JR
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 CAVENDISH DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-2732
Mailing Address - Country:US
Mailing Address - Phone:615-542-6439
Mailing Address - Fax:
Practice Address - Street 1:529 BRANDIES CIR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-0710
Practice Address - Country:US
Practice Address - Phone:615-797-8573
Practice Address - Fax:423-567-8573
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily