Healthcare Provider Details

I. General information

NPI: 1467400051
Provider Name (Legal Business Name): JERRY W JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 PRINCETON AVE SW SUITE 210
BIRMINGHAM AL
35211
US

IV. Provider business mailing address

817 PRINCETON AVE SW SUITE 210
BIRMINGHAM AL
35211
US

V. Phone/Fax

Practice location:
  • Phone: 205-226-5911
  • Fax: 205-226-5939
Mailing address:
  • Phone: 205-226-5911
  • Fax: 205-226-5939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number6279
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: