Provider Demographics
NPI:1033720701
Name:JACKSON, BRANDI (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5551 COUNTY ROAD 63
Mailing Address - Street 2:
Mailing Address - City:KILLEN
Mailing Address - State:AL
Mailing Address - Zip Code:35645
Mailing Address - Country:US
Mailing Address - Phone:256-710-7277
Mailing Address - Fax:
Practice Address - Street 1:TENNESSEE VALLEY PEDIATRICS
Practice Address - Street 2:234 KELLER PARK
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674
Practice Address - Country:US
Practice Address - Phone:256-381-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-108915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily