Healthcare Provider Details

I. General information

NPI: 1588736771
Provider Name (Legal Business Name): TERRY L JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WEST MAIN STREET
WATERTOWN TN
37184
US

IV. Provider business mailing address

121 WEST MAIN STREET
WATERTOWN TN
37184
US

V. Phone/Fax

Practice location:
  • Phone: 615-237-3631
  • Fax: 615-237-9906
Mailing address:
  • Phone: 615-237-3631
  • Fax: 615-237-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4316
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: