Provider Demographics
NPI:1952166985
Name:JACKSON, GRACIE ANNETTE
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:ANNETTE
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 1:235 GREENVILLE AVE UNIT 206
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-1116
Mailing Address - Country:US
Mailing Address - Phone:704-600-7181
Mailing Address - Fax:
Practice Address - Street 1:200 SWANNANOA RIVER RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2216
Practice Address - Country:US
Practice Address - Phone:828-470-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician