Basic Information
| Provider Information | |||||||||
| NPI: | 1104834555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | 5TH FLOOR ADAMS PAVILION | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015154529 | ||||||||
| FaxNumber: | 9015154599 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015155000 | ||||||||
| FaxNumber: | 9013750982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41430 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.