Provider Demographics
NPI:1982743274
Name:JACKSON, EARLINE (LPN CMLDT LMT)
Entity Type:Individual
Prefix:MRS
First Name:EARLINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN CMLDT LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SE MAYNARD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6945
Mailing Address - Country:US
Mailing Address - Phone:919-677-0767
Mailing Address - Fax:919-651-9322
Practice Address - Street 1:1230 SE MAYNARD RD STE 102
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6945
Practice Address - Country:US
Practice Address - Phone:919-677-0767
Practice Address - Fax:919-651-9322
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP01103600164W00000X
NC71590164W00000X
NC8517174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No164W00000XNursing Service ProvidersLicensed Practical Nurse