Provider Demographics
NPI:1013245745
Name:JACKSON, JENNIFER PARKER (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:PARKER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 TAVISTON DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6916
Mailing Address - Country:US
Mailing Address - Phone:704-219-9166
Mailing Address - Fax:
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:704-219-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC206943163W00000X, 363LP0808X
NC5006893363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse