Provider Demographics
NPI:1528001625
Name:JACKLIN, HAROLD N (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:N
Last Name:JACKLIN
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-7994
Practice Address - Street 1:1014 NORTH ELM STREET
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-7994
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15766207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8945505Medicaid
C80531Medicare UPIN
NC2063207AMedicare PIN