Provider Demographics
NPI:1033880059
Name:JACKSON CONSULTING AND SERVICES
Entity Type:Organization
Organization Name:JACKSON CONSULTING AND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LCAS
Authorized Official - Phone:336-254-8677
Mailing Address - Street 1:9008 BROAD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5199
Mailing Address - Country:US
Mailing Address - Phone:336-254-8677
Mailing Address - Fax:
Practice Address - Street 1:9008 BROAD RIDGE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-5199
Practice Address - Country:US
Practice Address - Phone:336-254-8677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D2236576Medicaid