Healthcare Provider Details

I. General information

NPI: 1851259071
Provider Name (Legal Business Name): LONNIE JEROME JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E 3RD ST
CHATTANOOGA TN
37403-2173
US

IV. Provider business mailing address

624 BELLE VISTA AVE
CHATTANOOGA TN
37411-2801
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-7000
  • Fax:
Mailing address:
  • Phone: 252-373-6996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34168
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number41251
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: