Healthcare Provider Details

I. General information

NPI: 1538090121
Provider Name (Legal Business Name): JEREMIAH LEE JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 NOAH LN
LA FOLLETTE TN
37766-5575
US

IV. Provider business mailing address

159 NOAH LN
LA FOLLETTE TN
37766-5575
US

V. Phone/Fax

Practice location:
  • Phone: 865-314-0005
  • Fax:
Mailing address:
  • Phone: 865-314-0005
  • Fax: 865-332-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8401
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: