Provider Demographics
NPI:1194350579
Name:JACKSON, SUSIE BERNICE
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:BERNICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 COPPER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-3242
Mailing Address - Country:US
Mailing Address - Phone:334-290-8131
Mailing Address - Fax:
Practice Address - Street 1:41 COPPER RIDGE CT
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-3242
Practice Address - Country:US
Practice Address - Phone:334-290-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3251374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3251OtherDEPARTMENT OF MENTAL HEALTH