Provider Demographics
NPI:1871012930
Name:JACKSON, TWANA
Entity Type:Individual
Prefix:MRS
First Name:TWANA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
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 9542
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35220-0542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 HUFFMAN RD STE 101B
Practice Address - Street 2:
Practice Address - City:CENTER POINT
Practice Address - State:AL
Practice Address - Zip Code:35215-5622
Practice Address - Country:US
Practice Address - Phone:205-844-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management