Provider Demographics
NPI:1699937557
Name:JACKSON, ELICEIA DIONNE (MD)
Entity type:Individual
Prefix:
First Name:ELICEIA
Middle Name:DIONNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12701 PADGETT SWITCH RD
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:AL
Mailing Address - Zip Code:36544-4011
Mailing Address - Country:US
Mailing Address - Phone:251-824-2174
Mailing Address - Fax:251-824-2286
Practice Address - Street 1:12701 PADGETT SWITCH RD
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-4011
Practice Address - Country:US
Practice Address - Phone:251-824-2174
Practice Address - Fax:251-824-2286
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21663207Q00000X
AL46088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09180751Medicaid
MS09180751Medicaid