Provider Demographics
NPI:1285913566
Name:JACKSON, ALICE MARIE (APN)
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 MADISON ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5975
Mailing Address - Country:US
Mailing Address - Phone:931-245-1701
Mailing Address - Fax:931-245-1720
Practice Address - Street 1:2690 MADISON ST
Practice Address - Street 2:SUITE 130
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5975
Practice Address - Country:US
Practice Address - Phone:931-245-1701
Practice Address - Fax:931-245-1720
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000015967363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner