Provider Demographics
NPI:1275536013
Name:JACKSON, MARK E (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3528
Mailing Address - Country:US
Mailing Address - Phone:828-698-4318
Mailing Address - Fax:828-698-4322
Practice Address - Street 1:800 FLEMING ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3528
Practice Address - Country:US
Practice Address - Phone:828-698-4318
Practice Address - Fax:828-698-4322
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC275259AMedicare PIN
NCP00223021Medicare PIN
NCS89655Medicare UPIN