Provider Demographics
NPI:1376586909
Name:GENANT, JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:GENANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 MALCOLM BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612-8079
Mailing Address - Country:US
Mailing Address - Phone:828-580-2811
Mailing Address - Fax:828-580-7083
Practice Address - Street 1:730 MALCOLM BLVD STE 230
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612-8079
Practice Address - Country:US
Practice Address - Phone:828-580-2811
Practice Address - Fax:828-580-7083
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1376586909Medicaid
NCBG5692428OtherDEA
2248684CMedicare PIN
NC8911064Medicare ID - Type Unspecified
NCG61935Medicare UPIN