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Contact Information

OTIS JACKSON JR
3311 KIMBALL AVE
MEMPHIS, TN38111-3846
 Phone: 901-207-4662
 Fax:
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Adult Development & Aging

103TA0700X 62 Psychologist, Clinical
Indicates primary specialty

NPI Profile & details for OTIS JACKSON JR · (Male)

NPI Number 1053710681
Status Active
Credentials
Entity Individual
Enumeration date 08/20/2014
Last updated 08/20/2014 - About 12 years ago
Sole proprietor 1 No
Identifiers
  • TN License # 1000000015105
Hospital affiliation(s) Not Available
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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