Provider Demographics
NPI:1396063012
Name:JACKSON MEDICAL SERVICES
Entity type:Organization
Organization Name:JACKSON MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-0266
Mailing Address - Street 1:81 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2042
Mailing Address - Country:US
Mailing Address - Phone:731-664-8300
Mailing Address - Fax:731-664-9376
Practice Address - Street 1:9 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2071
Practice Address - Country:US
Practice Address - Phone:731-661-0086
Practice Address - Fax:731-660-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty