Healthcare Provider Details

I. General information

NPI: 1982935532
Provider Name (Legal Business Name): JACKSON FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 HARLEY ST
SCOTTSBORO AL
35768-4219
US

IV. Provider business mailing address

PO BOX 56
SCOTTSBORO AL
35768-0056
US

V. Phone/Fax

Practice location:
  • Phone: 256-574-6157
  • Fax: 256-259-0560
Mailing address:
  • Phone: 256-574-6157
  • Fax: 256-259-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.9585
License Number StateAL

VIII. Authorized Official

Name: OSCAR V, FADUL
Title or Position: OWNER
Credential: M.D.
Phone: 256-574-6157