Provider Demographics
NPI:1609391572
Name:JACKSON, CARMESIA
Entity Type:Individual
Prefix:
First Name:CARMESIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SCHOOLHOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-1887
Mailing Address - Country:US
Mailing Address - Phone:336-749-0869
Mailing Address - Fax:336-749-0869
Practice Address - Street 1:2300 GATEWAY CENTRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-9669
Practice Address - Country:US
Practice Address - Phone:919-364-0735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1932000000XMedicaid