Provider Demographics
NPI:1194855072
Name:JACKSON, SHEILA
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELIA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4220 TROY HWY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2618
Mailing Address - Country:US
Mailing Address - Phone:334-612-2100
Mailing Address - Fax:331-612-2148
Practice Address - Street 1:5067 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-612-2100
Practice Address - Fax:334-612-2148
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL749332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies