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General NPI Number Information
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NPI Number | 1205866142
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Entity Type | Individual
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Provider Name | KEITH E JACKSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 100 RICE MINE RD N
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City | TUSCALOOSA
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State | AL
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Zip | 35406-2300
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Country | US
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Telephone | 205-354-0010
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Fax |
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Provider Business Mailing Address
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Address Line | 712 ROBIN RD
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City | BIRMINGHAM
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State | AL
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Zip | 35214-3524
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Country | US
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Telephone | 205-213-8420
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Fax | 205-798-5918
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 1-080730
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License Number State | AL
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