Provider Demographics
NPI:1336756600
Name:JACKSON, VIVIAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ELIZABETH
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 2722
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-2722
Mailing Address - Country:US
Mailing Address - Phone:205-215-3761
Mailing Address - Fax:
Practice Address - Street 1:1216 25TH ST N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35234-3139
Practice Address - Country:US
Practice Address - Phone:205-252-2994
Practice Address - Fax:205-254-6076
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-062778363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner