Provider Demographics
NPI:1215006192
Name:JACKSON, MISHI KAVON (MD)
Entity Type:Individual
Prefix:
First Name:MISHI
Middle Name:KAVON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1471 JAG BRANCH BLVD UNIT 103
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-6963
Practice Address - Country:US
Practice Address - Phone:336-515-7410
Practice Address - Fax:336-515-7419
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC42515OtherPARTNERS MEDICARE
NC5904650Medicaid
NC187165OtherMEDCOST
NC141YEOtherBCBS OF NC
NCP00650299OtherRR MEDICARE
H29248Medicare UPIN
NCP00650299OtherRR MEDICARE
NCNC6946AMedicare PIN
NC42515OtherPARTNERS MEDICARE