Provider Demographics
NPI:1124015284
Name:JACKSON, JANET E (MED, SLPC)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED, SLPC
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:ELIZABETH
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED SLPC
Mailing Address - Street 1:321 N. HULL ST.
Mailing Address - Street 2:'OLD ALABAMA TOWN'
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104
Mailing Address - Country:US
Mailing Address - Phone:334-269-4156
Mailing Address - Fax:334-269-4157
Practice Address - Street 1:321 N. HULL ST.
Practice Address - Street 2:'OLD ALABAMA TOWN'
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36104
Practice Address - Country:US
Practice Address - Phone:334-262-1434
Practice Address - Fax:334-262-1435
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1661101Y00000X
AL#1661/SLPC#448101YM0800X
AL#1661;#448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
515-09617OtherBLUE CROSS FED'L
AL051512316OtherBLUE CROSS