Provider Demographics
NPI:1396058707
Name:VICKERS, JENNIFER L (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:VICKERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2239
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35609-2239
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:1201 7TH ST SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3337
Practice Address - Country:US
Practice Address - Phone:256-341-2000
Practice Address - Fax:256-306-1691
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9306515367500000X
AL1-102952367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002708400Medicaid
FLDI838ZMedicare PIN