Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 31696 | TN |
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 31696 | TN |
NPI | 1407858368 |
---|---|
Provider Name | William Clay Jackson |
First Address | Germantown, TN 38138-3941 |
Second Address | Germantown, TN 38138-1762 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 24/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01751779 | (05) | MS |
1508274 | (05) | TN |
155538001 | (05) | AR |
H04663 | (02) | TN |