Provider Demographics
NPI:1427132422
Name:JACKSON, PATRICIA SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:SUZANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:JACKSON
Other - Last Name:FANNIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:225 VON KARMAN AVE
Mailing Address - Street 2:TULLAHOMA VA CLINIC
Mailing Address - City:ARNOLD AFB
Mailing Address - State:TN
Mailing Address - Zip Code:37389
Mailing Address - Country:US
Mailing Address - Phone:931-454-6134
Mailing Address - Fax:
Practice Address - Street 1:225 VON KARMAN AVE
Practice Address - Street 2:TULLAHOMA VA CLINIC
Practice Address - City:ARNOLD AFB
Practice Address - State:TN
Practice Address - Zip Code:37389
Practice Address - Country:US
Practice Address - Phone:931-454-6134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD017814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA98985Medicare UPIN