| Doctor Name: | COREY N JACKSON |
| NPI Number: | 1972873321 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 130 Mankin Pl La Vergne, TN - 370863048 |
| Business Phone Number: | 9317221443 |
| Business Fax Number: | |
| Mailing Address: | 130 Mankin Pl, LA VERGNE |
| State: | TN |
| Postal Code: | 370863048 |
| Phone Number: | 9317221443 |
| Fax Number: | |
| NPI Enumeration Date: | 01/03/2012 |
| NPI Last Update Date: | 01/03/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171WH0202X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Contractor |
| Taxonomy Specialization: | Home Modifications |
| Taxonomy Definition: | |