Healthcare Provider Details

I. General information

NPI: 1871012930
Provider Name (Legal Business Name): MRS. TWANA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 09/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 HUFFMAN RD STE 101B
CENTER POINT AL
35215-5622
US

IV. Provider business mailing address

PO BOX 9542
BIRMINGHAM AL
35220-0542
US

V. Phone/Fax

Practice location:
  • Phone: 205-844-5080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: