Provider Demographics
NPI:1992964373
Name:JACKSON, ALICIA (RT)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 AUDUBON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213
Mailing Address - Country:US
Mailing Address - Phone:502-609-3384
Mailing Address - Fax:
Practice Address - Street 1:1027 AUDUBON PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1303
Practice Address - Country:US
Practice Address - Phone:502-609-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator