Provider Demographics
NPI:1821380833
Name:JACKSON, RICHARD DEWITT II (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DEWITT
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:MD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-1800
Mailing Address - Fax:336-277-6981
Practice Address - Street 1:140 KIMEL PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6185
Practice Address - Country:US
Practice Address - Phone:336-718-7280
Practice Address - Fax:336-718-7290
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2012-019682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program