Individual
SHALONTA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
301 ANDREWS AVENUE, FORT RUCKER, AL 36360
(800) 261-7193
Mailing address
301 ANDREWS AVENUE, FORT RUCKER, AL 36360
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
2-066976
AL
Other
Enumeration date
11/17/2020
Last updated
11/17/2020
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