Provider Demographics
NPI:1386214898
Name:JACKSON, MELEAH (RN)
Entity Type:Individual
Prefix:
First Name:MELEAH
Middle Name:
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 1:5015 SUMATANGA RD
Mailing Address - Street 2:
Mailing Address - City:GALLANT
Mailing Address - State:AL
Mailing Address - Zip Code:35972-3136
Mailing Address - Country:US
Mailing Address - Phone:205-617-8722
Mailing Address - Fax:
Practice Address - Street 1:5015 SUMATANGA RD
Practice Address - Street 2:
Practice Address - City:GALLANT
Practice Address - State:AL
Practice Address - Zip Code:35972-3136
Practice Address - Country:US
Practice Address - Phone:205-617-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered