Provider Demographics
NPI:1144305152
Name:JACKSON, ROBERT ERIC (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ERIC
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 E OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1843
Mailing Address - Country:US
Mailing Address - Phone:239-262-3584
Mailing Address - Fax:
Practice Address - Street 1:374 BRINK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-3280
Practice Address - Country:US
Practice Address - Phone:931-762-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50448207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA362126638AMedicaid
GAI04560Medicare UPIN
GA202I119381Medicare PIN