Provider Demographics
NPI:1417733163
Name:JACKSON, JACQUELINE R
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 LEBRON RD
Mailing Address - Street 2:3100 LEBRON RD
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106
Mailing Address - Country:US
Mailing Address - Phone:334-235-2274
Mailing Address - Fax:
Practice Address - Street 1:3100 LEBRON RD
Practice Address - Street 2:3100 LEBRON RD
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106
Practice Address - Country:US
Practice Address - Phone:334-235-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALCO4539103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling