Provider Demographics
NPI:1447445820
Name:SHELIA JACKSON
Entity type:Organization
Organization Name:SHELIA JACKSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-612-2100
Mailing Address - Street 1:5646 BELL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-4118
Mailing Address - Country:US
Mailing Address - Phone:334-612-2100
Mailing Address - Fax:334-612-2148
Practice Address - Street 1:5646 BELL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-4118
Practice Address - Country:US
Practice Address - Phone:334-612-2100
Practice Address - Fax:334-612-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL749332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51539790OtherBLUECROSS BLUESHEILD
AL009910338Medicaid
AL5875000001Medicare NSC