Healthcare Provider Details

I. General information

NPI: 1104804764
Provider Name (Legal Business Name): ROBERT A JACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 08/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 QUAIL HOLLOW CIR
FRANKLIN TN
37067-5967
US

IV. Provider business mailing address

PO BOX 682749
FRANKLIN TN
37068-2749
US

V. Phone/Fax

Practice location:
  • Phone: 615-807-4020
  • Fax: 615-807-4022
Mailing address:
  • Phone: 615-807-4020
  • Fax: 615-807-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD13141
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: