MEDICARE: NOLA ANN JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		NC

General Provider Information

NPI Number	:	1326905506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLA ANN JACKSON

Provider Business Mailing Address
First Line	:	3100 STARMOUNT PARK BLVD APT 3113
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027-8530
Country	:	US
Telephone Number	:	631-402-4702
Fax Number	:

Provider Business Practice Location Address
First Line	:	4108 PARK RD STE 307
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-2261
Country	:	US
Telephone Number	:	980-288-2868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2026
Last Update Date	:	01/08/2026

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