Provider Demographics
NPI:1689287328
Name:JACKSON, ANTHONY BENEDICT (NP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:BENEDICT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BULL RIVER ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-3402
Mailing Address - Country:US
Mailing Address - Phone:850-543-9051
Mailing Address - Fax:
Practice Address - Street 1:3724 RALEIGH ROAD PKWY W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-9742
Practice Address - Country:US
Practice Address - Phone:252-246-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCJACK-AA4P9363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care