Healthcare Provider Details

I. General information

NPI: 1104740174
Provider Name (Legal Business Name): LEIGH ANN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16202 LOG CABIN RD
ATHENS AL
35611-8152
US

IV. Provider business mailing address

16202 LOG CABIN RD
ATHENS AL
35611-8152
US

V. Phone/Fax

Practice location:
  • Phone: 256-777-2095
  • Fax:
Mailing address:
  • Phone: 256-777-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5973C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: