Provider Demographics
NPI:1871610899
Name:JACKSON, HENRY CLARKE JR (ATC)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:CLARKE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-4951
Mailing Address - Country:US
Mailing Address - Phone:256-762-6367
Mailing Address - Fax:
Practice Address - Street 1:1119 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4951
Practice Address - Country:US
Practice Address - Phone:256-762-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer