Provider Demographics
NPI:1659317089
Name:JACKSON, GARLETTE B (CRNP)
Entity Type:Individual
Prefix:MS
First Name:GARLETTE
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 HEATHERSAGE CIR
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-7775
Mailing Address - Country:US
Mailing Address - Phone:204-633-3973
Mailing Address - Fax:205-633-3973
Practice Address - Street 1:1729 PINE STREET
Practice Address - Street 2:EMERGENCY ROOM C/O DR. STEVE O'MARA
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36105
Practice Address - Country:US
Practice Address - Phone:335-293-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-047192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P30126Medicare UPIN