Provider Demographics
NPI:1275773665
Name:JACKSON, CHRISTINE DENISE (APRN,FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 COURTHOUSE SQ
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4809
Mailing Address - Country:US
Mailing Address - Phone:251-580-2555
Mailing Address - Fax:
Practice Address - Street 1:324 COURTHOUSE SQ
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4809
Practice Address - Country:US
Practice Address - Phone:251-580-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-130303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011846OtherMEDICARE GROUP NUMBER
AL630000013Medicaid
AL1063439065OtherNPI GROUP PAYEE NUMBER