Provider Demographics
NPI:1104860055
Name:JACKSON, NATHAN OSCAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:OSCAR
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 1:216 CHATEAU PL
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-8767
Mailing Address - Country:US
Mailing Address - Phone:919-968-6339
Mailing Address - Fax:336-599-8366
Practice Address - Street 1:355C S MADISON BLVD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5464
Practice Address - Country:US
Practice Address - Phone:336-599-8366
Practice Address - Fax:336-599-8366
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC399552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8945696Medicaid
NC2162692Medicare ID - Type Unspecified
NC8945696Medicaid