Provider Demographics
NPI:1548432248
Name:MARSHALL JACKSON MRA
Entity Type:Organization
Organization Name:MARSHALL JACKSON MRA
Other - Org Name:EARLY INTERVENTION
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:W
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-582-7528
Mailing Address - Street 1:2024 GUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-2113
Mailing Address - Country:US
Mailing Address - Phone:256-582-7528
Mailing Address - Fax:256-582-7311
Practice Address - Street 1:2024 GUNTER AVE
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2113
Practice Address - Country:US
Practice Address - Phone:256-582-7528
Practice Address - Fax:256-582-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management