Provider Demographics
NPI:1558335984
Name:JACKSON, JAMES C (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 851417
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-1417
Mailing Address - Country:US
Mailing Address - Phone:251-342-3000
Mailing Address - Fax:251-342-3043
Practice Address - Street 1:3719 DAUPHIN ST
Practice Address - Street 2:SPRINGHILL MED CTR ANESTHESIA DEPT
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1753
Practice Address - Country:US
Practice Address - Phone:251-342-3000
Practice Address - Fax:251-342-3043
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1020688367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALCN0216OtherMEDICARE TRAVELERS
AL000022017OtherMEDICARE TRAVELERS PIN
AL000022017Medicaid
AL105361Medicaid
AL000022017Medicaid
AL105361Medicaid