Healthcare Provider Details

I. General information

NPI: 1407858368
Provider Name (Legal Business Name): WILLIAM CLAY JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7945 WOLF RIVER BLVD
GERMANTOWN TN
38138-1762
US

IV. Provider business mailing address

7714 POPLAR AVE STE 200
GERMANTOWN TN
38138-3941
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-0055
  • Fax: 901-685-2969
Mailing address:
  • Phone: 901-683-0055
  • Fax: 901-685-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31696
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number31696
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: