Healthcare Provider Details

I. General information

NPI: 1124715958
Provider Name (Legal Business Name): JAMES SCULLY JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 S CLAYBROOK ST STE A206
MEMPHIS TN
38104-3539
US

IV. Provider business mailing address

2540 BROAD AVE APT 452
MEMPHIS TN
38112-2644
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-7509
  • Fax:
Mailing address:
  • Phone: 678-463-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number72921
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: