Healthcare Provider Details

I. General information

NPI: 1669115770
Provider Name (Legal Business Name): SCOTT CHRISTIAN JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2022
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 PARK AVE STE 210
MEMPHIS TN
38119-3530
US

IV. Provider business mailing address

17649 ROCKWOOD ARBOR DR
EUREKA MO
63025-4035
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-0850
  • Fax:
Mailing address:
  • Phone: 636-236-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12245
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: