Provider Demographics
NPI:1114516010
Name:JACKSON, CAROLINE ARDEN
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ARDEN
Last Name: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 1:7075 LAKE RUN DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35242-7503
Mailing Address - Country:US
Mailing Address - Phone:205-789-7079
Mailing Address - Fax:
Practice Address - Street 1:7075 LAKE RUN DR
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35242-7503
Practice Address - Country:US
Practice Address - Phone:205-789-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program