Provider Demographics
NPI:1730899352
Name:JACKSON, NAOMI NAMROTA (PA-C)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:NAMROTA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 BARCLAY POINTE BLVD APT 9201
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-1107
Mailing Address - Country:US
Mailing Address - Phone:731-535-1629
Mailing Address - Fax:
Practice Address - Street 1:2909 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1221
Practice Address - Country:US
Practice Address - Phone:910-795-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12831208VP0000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine