Provider Demographics
NPI:1336198829
Name:JACKSON, NORMA (FNP)
Entity type:Individual
Prefix:
First Name:NORMA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6170 SHALLOWFORD RD
Mailing Address - Street 2:STE 101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1892
Mailing Address - Country:US
Mailing Address - Phone:423-648-4500
Mailing Address - Fax:423-855-7563
Practice Address - Street 1:1494 STUART RD.
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312
Practice Address - Country:US
Practice Address - Phone:423-648-7699
Practice Address - Fax:423-648-7695
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4162413OtherBLUE CROSS BLUE SHIELD
TN4162413OtherBLUE CROSS BLUE SHIELD