Basic Information
| Provider Information | |||||||||
| NPI: | 1760879993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SONIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3799 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312457000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 490 DUNLOP LN BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312458100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2015 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 60534 | TN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | Q042787 | 05 | TN | MEDICAID |