Healthcare Provider Details

I. General information

NPI: 1174699946
Provider Name (Legal Business Name): JANICE GIBSON JACKSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

1919 7TH AVENUE SOUTH SDB BOX 58
BIRMINGHAM AL
35294-0001
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-5174
  • Fax: 205-939-9796
Mailing address:
  • Phone: 205-934-2340
  • Fax: 205-934-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3255
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: