Provider Demographics
NPI:1407491673
Name:JACKSON, KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 PELZER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-2147
Mailing Address - Country:US
Mailing Address - Phone:334-649-6894
Mailing Address - Fax:334-649-6894
Practice Address - Street 1:2934 PELZER AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2147
Practice Address - Country:US
Practice Address - Phone:334-354-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health