Provider Demographics
NPI:1568479715
Name:JACKSON, MICHELLE S (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 AIRPORT BLVD
Mailing Address - Street 2:STE A101
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6767
Mailing Address - Country:US
Mailing Address - Phone:251-378-6209
Mailing Address - Fax:251-378-6222
Practice Address - Street 1:2423 SCHILLINGER RD S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4136
Practice Address - Country:US
Practice Address - Phone:251-605-9506
Practice Address - Fax:251-660-5949
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00018274207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051553281Medicaid
AL051553281Medicaid
051553281Medicare ID - Type Unspecified