Provider Demographics
NPI:1740260611
Name:JACKSON-CREEF, ROBIN DENISE (PA)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:DENISE
Last Name:JACKSON-CREEF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:DENISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:110 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1522
Mailing Address - Country:US
Mailing Address - Phone:336-768-3361
Mailing Address - Fax:336-768-4131
Practice Address - Street 1:110 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-768-3361
Practice Address - Fax:336-768-4131
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1740260611Medicaid
NC2755041Medicare PIN