Healthcare Provider Details

I. General information

NPI: 1750729646
Provider Name (Legal Business Name): MARILYN SLEDGE JACKSON/SAFE HARBOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 LONGFIELD CT
MONTGOMERY AL
36117-8055
US

IV. Provider business mailing address

2325 BRIAR GATE DR
MONTGOMERY AL
36116-2154
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-9009
  • Fax: 334-288-9497
Mailing address:
  • Phone: 334-235-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0942-2160C
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2160C
License Number StateAL

VIII. Authorized Official

Name: MRS. MARILYN SLEDGE JACKSON
Title or Position: THERAPIST
Credential: LCSW/PIP
Phone: 334-235-8158