Provider Demographics
NPI:1063838878
Name:MCMILLAN JACKSON, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:MCMILLAN JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:PRICHARD
Mailing Address - State:AL
Mailing Address - Zip Code:36610-3910
Mailing Address - Country:US
Mailing Address - Phone:251-423-1897
Mailing Address - Fax:251-452-4797
Practice Address - Street 1:2117 LUCKNER CT
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-2618
Practice Address - Country:US
Practice Address - Phone:251-423-8197
Practice Address - Fax:251-452-4797
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities