Provider Demographics
NPI:1275046153
Name:JACKSON, BRANDON LAMARR
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LAMARR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BRUNSWICK ST.
Mailing Address - Street 2:420
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2246
Mailing Address - Country:US
Mailing Address - Phone:704-977-1412
Mailing Address - Fax:
Practice Address - Street 1:400 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2246
Practice Address - Country:US
Practice Address - Phone:704-977-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide