Provider Demographics
NPI:1093887960
Name:JACKSON, BROOKE A (MD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 EAST NC HIGHWAY 54
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713
Mailing Address - Country:US
Mailing Address - Phone:919-294-9440
Mailing Address - Fax:919-237-3899
Practice Address - Street 1:245 E NC HIGHWAY 54
Practice Address - Street 2:SUITE 202
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2551
Practice Address - Country:US
Practice Address - Phone:919-294-9440
Practice Address - Fax:919-237-3899
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093014207N00000X
NC2013-00616207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
01633086OtherBCBS
210049Medicare ID - Type Unspecified
01633086OtherBCBS