Healthcare Provider Details

I. General information

NPI: 1306842356
Provider Name (Legal Business Name): BRIAN D JACKSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HATCHER LN
COLUMBIA TN
38401-3531
US

IV. Provider business mailing address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

V. Phone/Fax

Practice location:
  • Phone: 615-220-8788
  • Fax: 615-220-8688
Mailing address:
  • Phone: 615-239-2018
  • Fax: 615-851-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number436
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: