Provider Demographics
NPI:1629273735
Name:JACKSON, JONATHAN WESLEY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:WESLEY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
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 2257
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28353-2257
Mailing Address - Country:US
Mailing Address - Phone:910-610-4011
Mailing Address - Fax:910-276-0571
Practice Address - Street 1:500 LAUCHWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5501
Practice Address - Country:US
Practice Address - Phone:910-610-4011
Practice Address - Fax:910-276-9412
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN3271367500000X
NC190408367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC077609OtherCCNA CERTIFICATION
NC8053701Medicaid
NC8053701Medicaid