Individual
LAWRENCE RICHARD JACKSON JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
104 HILLWOOD DR, WAVERLY, TN 37185-2116
(931) 296-3555
(931) 296-9085
Mailing address
PO BOX 270, WAVERLY, TN 37185-0270
(931) 296-3555
(931) 296-9085
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
20215
TN
207Q00000X
Family Medicine Physician
Primary
MD0000020215
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0151975
BCBS
TN
01
—
223121700
DEPT OF LABOR
TN
05
—
3724150
—
TN
Enumeration date
01/10/2007
Last updated
08/07/2023
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