Provider Demographics
NPI:1598706855
Name:JACKSON, P BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:P
Middle Name:BRIAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:BRIAN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7100 SIX FORKS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6156
Mailing Address - Country:US
Mailing Address - Phone:919-847-0187
Mailing Address - Fax:919-676-2231
Practice Address - Street 1:6825 PARKER FARM DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3168
Practice Address - Country:US
Practice Address - Phone:910-452-0554
Practice Address - Fax:910-452-0767
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1294152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC809042BMedicaid
NC093VYOtherBLUE CROSS BLUE SHIELD
NCP00789509OtherMEDICARE RAILROAD CARRIER
NCP00789509OtherMEDICARE RAILROAD CARRIER
NC246651CMedicare PIN
NC809042BMedicaid