Provider Demographics
NPI:1386794816
Name:JACKSON, LAWRENCE RICHARD JR (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:RICHARD
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-0270
Mailing Address - Country:US
Mailing Address - Phone:931-296-3555
Mailing Address - Fax:931-296-9085
Practice Address - Street 1:104 HILLWOOD DR
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-2116
Practice Address - Country:US
Practice Address - Phone:931-296-3555
Practice Address - Fax:931-296-9085
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20215207Q00000X
TNMD0000020215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN223121700OtherDEPT OF LABOR
TN0151975OtherBCBS
TN3724150Medicaid
TN223121700OtherDEPT OF LABOR
TN3724150Medicaid