Provider Demographics
NPI:1982935532
Name:JACKSON FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:V,
Authorized Official - Last Name:FADUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-574-6157
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-0056
Mailing Address - Country:US
Mailing Address - Phone:256-574-6157
Mailing Address - Fax:256-259-0560
Practice Address - Street 1:506 HARLEY ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4219
Practice Address - Country:US
Practice Address - Phone:256-574-6157
Practice Address - Fax:256-259-0560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.9585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty