Provider Demographics
NPI:1215179320
Name:JACKSON, CARRIE ANN (MED)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 WYNTERCREST LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4518
Mailing Address - Country:US
Mailing Address - Phone:919-619-3388
Mailing Address - Fax:
Practice Address - Street 1:2721 WYNTERCREST LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-4518
Practice Address - Country:US
Practice Address - Phone:919-619-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional