MEDICARE: DEBORAH JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F0916577	AL

General Provider Information

NPI Number	:	1073057279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH JACKSON

Provider Business Mailing Address
First Line	:	2900 E UNIVERSITY DR STE 110
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-7729
Country	:	US
Telephone Number	:	334-502-2440
Fax Number	:	334-502-2460

Provider Business Practice Location Address
First Line	:	2900 E UNIVERSITY DR STE 110
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-7729
Country	:	US
Telephone Number	:	334-502-2440
Fax Number	:	334-502-2460

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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