Provider Demographics
NPI:1073587598
Name:JACKSON, WOODY H (MD)
Entity Type:Individual
Prefix:DR
First Name:WOODY
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3515
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27515-3515
Mailing Address - Country:US
Mailing Address - Phone:919-308-1562
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-815-5830
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063122L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919880Medicaid
PA001688698Medicaid
PA232359401OtherMAIN LINE HEALTHCARE
SCQ0029KMedicaid
SCQ0029KMedicaid
NCNC5779AMedicare PIN
G80708Medicare UPIN