Provider Demographics
NPI:1891311734
Name:JACKSON, SHARON RENA
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:RENA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
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 14305
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27620-4305
Mailing Address - Country:US
Mailing Address - Phone:919-434-5689
Mailing Address - Fax:
Practice Address - Street 1:2847 JACK RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-8421
Practice Address - Country:US
Practice Address - Phone:919-434-5689
Practice Address - Fax:919-679-4049
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NC11452174H00000X
NC269855163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health