Provider Demographics
NPI:1497445811
Name:JACKSON, SAMUEL HOWARD JR (CRNP-FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HOWARD
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:CRNP-FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 CRESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-1229
Mailing Address - Country:US
Mailing Address - Phone:205-838-6775
Mailing Address - Fax:
Practice Address - Street 1:6074 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:AL
Practice Address - Zip Code:35126-2300
Practice Address - Country:US
Practice Address - Phone:205-243-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111NX0100X111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health