Provider Demographics
NPI:1417565193
Name:PETTY, JACKSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:PETTY
Suffix:
Gender:U
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2208
Mailing Address - Country:US
Mailing Address - Phone:931-454-9499
Mailing Address - Fax:931-454-9499
Practice Address - Street 1:2118 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2208
Practice Address - Country:US
Practice Address - Phone:931-454-9499
Practice Address - Fax:931-454-9499
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2046571223G0001X, 1223G0001X
TN114231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice