Healthcare Provider Details

I. General information

NPI: 1780381376
Provider Name (Legal Business Name): MANDI JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29653 ANCHOR CROSS BLVD
DAPHNE AL
36526-9594
US

IV. Provider business mailing address

1851 N MCKENZIE ST STE 106
FOLEY AL
36535-4704
US

V. Phone/Fax

Practice location:
  • Phone: 251-418-0592
  • Fax:
Mailing address:
  • Phone: 251-943-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0139729TELE
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5025256
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11024768
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-136796
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: