Healthcare Provider Details

I. General information

NPI: 1396063012
Provider Name (Legal Business Name): JACKSON MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 PHYSICIANS DR
JACKSON TN
38305-2071
US

IV. Provider business mailing address

81 STONEBRIDGE BLVD
JACKSON TN
38305-2042
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-0086
  • Fax: 731-660-9055
Mailing address:
  • Phone: 731-664-8300
  • Fax: 731-664-9376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: BOB SOUDER
Title or Position: OWNER
Credential:
Phone: 731-664-0266