Provider Demographics
NPI:1942290606
Name:JACKSON, PAUL DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DENNIS
Last Name:JACKSON
Suffix:
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 1:2065 21ST ST. SE, APT. O
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-3479
Mailing Address - Country:US
Mailing Address - Phone:828-328-3431
Mailing Address - Fax:828-328-3431
Practice Address - Street 1:2065 21ST ST SE APT O
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-3479
Practice Address - Country:US
Practice Address - Phone:828-328-3431
Practice Address - Fax:828-328-3431
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS085692084P0800X
NC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D73581Medicare UPIN