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General NPI Number Information
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NPI Number | 1902535495
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Entity Type | Individual
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Provider Name | JACKSON TUCKER GREEN DDS
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Gender | Male
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Dates
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Enumeration Date | 06/09/2022
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 875 UNION AVE
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City | MEMPHIS
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State | TN
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Zip | 38163-2211
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Country | US
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Telephone | 901-448-1731
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Fax |
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Provider Business Mailing Address
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Address Line | 7794 KINGS COLLEGE AVE APT 382
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City | GERMANTOWN
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State | TN
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Zip | 38138-2098
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D011416
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | D011416
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License Number State | AZ
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