Provider Demographics
NPI:1952967408
Name:JACKSON, GERTIE LOU
Entity Type:Individual
Prefix:MRS
First Name:GERTIE
Middle Name:LOU
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 1:315 TRAM RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-6436
Mailing Address - Country:US
Mailing Address - Phone:252-550-1150
Mailing Address - Fax:
Practice Address - Street 1:315 TRAM RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-6436
Practice Address - Country:US
Practice Address - Phone:252-550-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC05Medicaid