MEDICARE: ELBERT E JACKSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS2474	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	557446	OTHER	TN	UCCI

General Provider Information

NPI Number	:	1356419055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELBERT E JACKSON DDS

Provider Business Mailing Address
First Line	:	200 GLEAVES ST
Second Line	:	SUITE C
City	:	MADISON
State	:	TN
Zip	:	37115-2154
Country	:	US
Telephone Number	:	615-859-1881
Fax Number	:	615-865-7723

Provider Business Practice Location Address
First Line	:	200 GLEAVES ST
Second Line	:	SUITE C
City	:	MADISON
State	:	TN
Zip	:	37115-2154
Country	:	US
Telephone Number	:	615-859-1881
Fax Number	:	615-865-7723

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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Directions to “ ELBERT E JACKSON DDS” Practice Location

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