Provider Demographics
NPI:1972873321
Name:JACKSON, COREY N
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MANKIN PL
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-3048
Mailing Address - Country:US
Mailing Address - Phone:931-722-1443
Mailing Address - Fax:
Practice Address - Street 1:130 MANKIN PL
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-3048
Practice Address - Country:US
Practice Address - Phone:931-722-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications