Basic Information
| Provider Information | |||||||||
| NPI: | 1396063012 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON MEDICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 STONEBRIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316648300 | ||||||||
| FaxNumber: | 7316649376 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316610086 | ||||||||
| FaxNumber: | 7316609055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7316640266 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.