Provider Demographics
NPI:1144710831
Name:JACKSON MEDICAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:JACKSON MEDICAL ASSOCIATES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-450-7064
Mailing Address - Street 1:228 BONNIE LN
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-8553
Mailing Address - Country:US
Mailing Address - Phone:828-989-6668
Mailing Address - Fax:855-422-2581
Practice Address - Street 1:251 SHELTON ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-3362
Practice Address - Country:US
Practice Address - Phone:828-456-8365
Practice Address - Fax:855-422-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000670Medicaid