Provider Demographics
NPI:1861754004
Name:JACKSON, JONATHAN GEORGE (RN)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:GEORGE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 STOCKTON RD
Mailing Address - Street 2:
Mailing Address - City:CHUCKEY
Mailing Address - State:TN
Mailing Address - Zip Code:37641-5900
Mailing Address - Country:US
Mailing Address - Phone:423-552-0996
Mailing Address - Fax:
Practice Address - Street 1:120 STOCKTON RD
Practice Address - Street 2:
Practice Address - City:CHUCKEY
Practice Address - State:TN
Practice Address - Zip Code:37641-5900
Practice Address - Country:US
Practice Address - Phone:423-552-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000-176430163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical