Basic Information
| Provider Information | |||||||||
| NPI: | 1568479715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 AIRPORT BLVD | ||||||||
| Address2: | STE A101 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366086767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513786209 | ||||||||
| FaxNumber: | 2513786222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 SCHILLINGER RD S | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366954136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516059506 | ||||||||
| FaxNumber: | 2516605949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00018274 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051553281 | 05 | AL | MEDICAID |