Provider Demographics
NPI:1588736771
Name:JACKSON, TERRY L (DDS)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37184
Mailing Address - Country:US
Mailing Address - Phone:615-237-3631
Mailing Address - Fax:615-237-9906
Practice Address - Street 1:121 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:TN
Practice Address - Zip Code:37184
Practice Address - Country:US
Practice Address - Phone:615-237-3631
Practice Address - Fax:615-237-9906
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist