Provider Demographics
NPI:1255706438
Name:JACKSON, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-3930
Mailing Address - Country:US
Mailing Address - Phone:205-523-7429
Mailing Address - Fax:
Practice Address - Street 1:2021 40TH AVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3930
Practice Address - Country:US
Practice Address - Phone:205-523-7429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL372500000X, 372600000X, 3747P1801X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376K00000XNursing Service Related ProvidersNurse's Aide