MEDICARE: DR. RICHARD EVAN JACKSON MD

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	2084P0800X	Psychiatry Physician	15545	TN
2	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	15545	TN

General Provider Information

NPI Number	:	1457359770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD EVAN JACKSON MD

Provider Business Mailing Address
First Line	:	106 PINNACLE DR
Second Line	:	SUITE 107
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-6602
Country	:	US
Telephone Number	:	423-328-7332
Fax Number	:	423-207-1222

Provider Business Practice Location Address
First Line	:	106 PINNACLE DR
Second Line	:	SUITE 107
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-6602
Country	:	US
Telephone Number	:	423-328-7332
Fax Number	:	423-207-1222

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	07/17/2014

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