Provider Demographics
NPI:1942699566
Name:JACKSON, VICKIE LYNNE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNNE
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 1:29495 COPPERHEAD LN
Mailing Address - Street 2:
Mailing Address - City:ELKMONT
Mailing Address - State:AL
Mailing Address - Zip Code:35620-5931
Mailing Address - Country:US
Mailing Address - Phone:256-732-4452
Mailing Address - Fax:256-732-4430
Practice Address - Street 1:29495 COPPERHEAD LN
Practice Address - Street 2:
Practice Address - City:ELKMONT
Practice Address - State:AL
Practice Address - Zip Code:35620-5931
Practice Address - Country:US
Practice Address - Phone:256-732-4452
Practice Address - Fax:256-732-4430
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-067105163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)