Otis Jackson Jr.

Primary specialty

Adult Development & Aging PsychologistTaxonomy code 103TA0700X

License

1000000015105 Issued in TN

Practice address

3311 Kimball Ave
Memphis, TN 38111-3846

Phone

(901) 207-4662

NPI assigned

Aug 20, 2014

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Wright Enhancement Center

  • Adult Development & Aging Psychologist
  • Memphis, TN
  • NPI 1841696101
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1408492800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1408492800000",
    "number": "1053710681",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1092 CENTER RIDGE RD",
            "city": "COLLIERVILLE",
            "state": "TN",
            "postal_code": "380179207",
            "telephone_number": "901-870-6847",
            "fax_number": "901-854-9779"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3311 KIMBALL AVE",
            "city": "MEMPHIS",
            "state": "TN",
            "postal_code": "381113846",
            "telephone_number": "901-207-4662"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "OTIS",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-08-20",
        "last_updated": "2014-08-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TA0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Adult Development & Aging",
            "state": "TN",
            "license": "1000000015105",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mary Michael Jackson, DO
• Melody Jackson, D.C.
• Mika Tralayne Jackson, APRN, PMHNP
• Milissa Jackson, D.PH.
• Nevonda Venice Jackson, PHARM.D.
• Pamela A Jackson
• Rasheedah Jackson
• Regina Rodgers Jackson, FNP
• Ricky Jackson
• Ruth Jackson, APN

• Adult Development & Aging Psychologist in Memphis, TN
• Providers in Memphis, TN by specialty
• Adult Development & Aging Psychologist in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 20, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.