Healthcare Provider Details

I. General information

NPI: 1053710681
Provider Name (Legal Business Name): MR. OTIS JACKSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 KIMBALL AVE
MEMPHIS TN
38111-3846
US

IV. Provider business mailing address

1092 CENTER RIDGE RD
COLLIERVILLE TN
38017-9207
US

V. Phone/Fax

Practice location:
  • Phone: 901-207-4662
  • Fax:
Mailing address:
  • Phone: 901-870-6847
  • Fax: 901-854-9779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1000000015105
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: