Provider Demographics
NPI:1346286010
Name:JACKSON, ANITA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
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 1046
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1046
Mailing Address - Country:US
Mailing Address - Phone:910-738-1919
Mailing Address - Fax:910-738-1991
Practice Address - Street 1:4315 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2460
Practice Address - Country:US
Practice Address - Phone:910-738-1919
Practice Address - Fax:910-738-1991
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700991207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0215YOtherBCBS
NC892015YMedicaid
NC103883OtherUNITEDHEALTH CARE
NC040013091OtherRAILROAD MEDICARE
NC892015YMedicaid
NC2243423Medicare PIN