Provider Demographics
NPI:1215372644
Name:JACKSON, BRENDA LEE (RN)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 HORNADY DR
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36460-8658
Mailing Address - Country:US
Mailing Address - Phone:261-575-4837
Mailing Address - Fax:251-575-5266
Practice Address - Street 1:530 HORNADY DR
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36460-8658
Practice Address - Country:US
Practice Address - Phone:261-575-4837
Practice Address - Fax:251-575-5266
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-138402163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health