Provider Demographics
NPI:1639202336
Name:JACKSON, TINA MARIE (ANP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 CRICKETT RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-9327
Mailing Address - Country:US
Mailing Address - Phone:919-266-6565
Mailing Address - Fax:919-233-0343
Practice Address - Street 1:300 KEISLER DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518
Practice Address - Country:US
Practice Address - Phone:919-233-0059
Practice Address - Fax:919-233-0343
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900192363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health