MEDICARE: SHELIA 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	332B00000X	Durable Medical Equipment & Medical Supplies	749	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51539790	OTHER	AL	BLUECROSS BLUESHEILD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447445820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHELIA JACKSON

Provider Business Mailing Address
First Line	:	5646 BELL RD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-4118
Country	:	US
Telephone Number	:	334-612-2100
Fax Number	:	334-612-2148

Provider Business Practice Location Address
First Line	:	5646 BELL RD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-4118
Country	:	US
Telephone Number	:	334-612-2100
Fax Number	:	334-612-2148

Authorized Official
Title or Position	:	OWNER
Name	:	SHELIA D JACKSON
Credential	:
Telephone Number	:	334-612-2100

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	06/11/2012

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Directions to “SHELIA JACKSON ” Practice Location

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