Provider Demographics
NPI:1790799211
Name:JACKSON, STEPHEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 N MCKENZIE ST
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2247
Mailing Address - Country:US
Mailing Address - Phone:251-949-3710
Mailing Address - Fax:251-949-3715
Practice Address - Street 1:1613 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2247
Practice Address - Country:US
Practice Address - Phone:251-949-3710
Practice Address - Fax:251-949-3715
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00015458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04685310Medicaid
AL235881Medicaid
P00004569OtherRR MCR
AL051553469Medicaid
ALCK7413OtherRR MEDICARE GROUP ID
AL51516833OtherBCBS
051553469Medicare PIN