Individual
KENNETH S JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP
Contact information
Practice address
123 MAPLE ST, BRUCETON, TN 38317-1819
(731) 586-4800
(731) 352-4459
Mailing address
205 HOSPITAL DR, SUITE A, MC KENZIE, TN 38201-1649
(731) 352-7907
(731) 352-4459
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
17382
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10350I2435
MEDICARE PTAN
TN
01
—
3380640
GROUP MEDICAID
TN
05
—
Q001235
—
TN
Enumeration date
02/25/2013
Last updated
10/10/2025
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