Healthcare Provider Details

I. General information

NPI: 1417882200
Provider Name (Legal Business Name): NAKISA J JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TWINING ST BLDG 760
MONTGOMERY AL
36112-6027
US

IV. Provider business mailing address

1831 COTTON BLOSSOM WAY
PRATTVILLE AL
36067-6631
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-0199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2-065789
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: