Healthcare Provider Details

I. General information

NPI: 1265070445
Provider Name (Legal Business Name): MS. JALEESA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SELMA AVE
SELMA AL
36701-5825
US

IV. Provider business mailing address

101 PARK PL
SELMA AL
36701-6764
US

V. Phone/Fax

Practice location:
  • Phone: 334-877-1490
  • Fax: 334-877-1491
Mailing address:
  • Phone: 334-407-1946
  • Fax: 334-874-7435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: