Provider Demographics
NPI:1750517835
Name:JACKSON, BETHANY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-2729
Mailing Address - Country:US
Mailing Address - Phone:256-284-7280
Mailing Address - Fax:256-284-7284
Practice Address - Street 1:1941 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-2729
Practice Address - Country:US
Practice Address - Phone:256-284-7280
Practice Address - Fax:256-284-7284
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33311207RE0101X
NC156754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10211I2802Medicare PIN