Provider Demographics
NPI:1053710681
Name:JACKSON, OTIS JR
Entity type:Individual
Prefix:MR
First Name:OTIS
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9207
Mailing Address - Country:US
Mailing Address - Phone:901-870-6847
Mailing Address - Fax:901-854-9779
Practice Address - Street 1:3311 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-3846
Practice Address - Country:US
Practice Address - Phone:901-207-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000015105103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging