Basic Information
| Provider Information | |||||||||
| NPI: | 1194001677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 20TH AVE N STE 403 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372035180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152847260 | ||||||||
| FaxNumber: | 6152847501 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 22ND AVE N | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153295144 | ||||||||
| FaxNumber: | 6152842595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000016052 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01028866 | 01 | TN | RR MEDICARE | OTHER | 1527245 | 05 | TN | MEDICAID | 6012072 | 01 | TN | BLUE CROSS-BLUE SHIELD | OTHER |