Individual
KELLI JOHNSON JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6814 CHARLOTTE PIKE, NASHVILLE, TN 37209-4206
(615) 352-9699
Mailing address
1221 BUCKHEAD DR, BRENTWOOD, TN 37027-7878
(615) 837-8422
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1566
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3940088
—
TN
01
—
4134928
BCBS & TNCARE SELECT #
TN
01
—
P00265658
RAILROAD MEDICARE PROV #
TN
Enumeration date
07/21/2006
Last updated
06/03/2019
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