Provider Demographics
NPI:1659572212
Name:JACKSON, PAULETTE (CPED RESP THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPED RESP THERAPIST
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 98
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NC
Mailing Address - Zip Code:27849
Mailing Address - Country:US
Mailing Address - Phone:252-348-4000
Mailing Address - Fax:252-348-4001
Practice Address - Street 1:108 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NC
Practice Address - Zip Code:27849
Practice Address - Country:US
Practice Address - Phone:252-826-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9579225000000X
NCA1145227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7490010Medicaid
NC7795134Medicaid