MEDICARE: LABRINA F JACKSON ATC, LAT

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	2255A2300X	Athletic Trainer	865	AL

General Provider Information

NPI Number	:	1518082940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LABRINA F JACKSON ATC, LAT

Provider Business Mailing Address
First Line	:	5740 ARBOR STATION RD APT D
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-4673
Country	:	US
Telephone Number	:	334-531-0158
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 S JACKSON ST
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36104-5732
Country	:	US
Telephone Number	:	334-229-7627
Fax Number	:

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	05/29/2008

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