Healthcare Provider Details

I. General information

NPI: 1639712581
Provider Name (Legal Business Name): JORDAN LEIGH JACKSON L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 5TH AVE S
IRONDALE AL
35210
US

IV. Provider business mailing address

1914 5TH AVE S
IRONDALE AL
35210
US

V. Phone/Fax

Practice location:
  • Phone: 205-296-2413
  • Fax:
Mailing address:
  • Phone: 205-296-2413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4135
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: