Provider Demographics
NPI:1578869475
Name:JACKSON, BRADLEY DANIEL (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DANIEL
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 1:1301 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-1306
Mailing Address - Country:US
Mailing Address - Phone:251-809-8429
Mailing Address - Fax:
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7042
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9312860367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL592-13562OtherBLUE CROSS BLUE SHIELD
FLG00MEOtherBLUE CROSS BLUE SHIELD
P00959140OtherMEDICARE RAILROAD
AL126061Medicaid
FL003243800Medicaid
FLG00MEOtherBLUE CROSS BLUE SHIELD