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General NPI Number Information
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NPI Number | 1942699566
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Entity Type | Individual
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Provider Name | VICKIE LYNNE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 01/20/2015
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 29495 COPPERHEAD LN
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City | ELKMONT
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State | AL
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Zip | 35620-5931
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Country | US
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Telephone | 256-732-4452
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Fax | 256-732-4430
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Provider Business Mailing Address
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Address Line | 29495 COPPERHEAD LN
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City | ELKMONT
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State | AL
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Zip | 35620-5931
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Country | US
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Telephone | 256-732-4452
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Fax | 256-732-4430
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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 | 163WA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
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License Number | 1-067105
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License Number State | AL
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