Healthcare Provider Details

I. General information

NPI: 1831289586
Provider Name (Legal Business Name): CHERYL JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27599-0001
US

IV. Provider business mailing address

143 W FRANKLIN ST
CHAPEL HILL NC
27516-2539
US

V. Phone/Fax

Practice location:
  • Phone: 919-966-8596
  • Fax: 919-843-5515
Mailing address:
  • Phone: 919-966-8596
  • Fax: 919-843-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94-00282
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number94-00282
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier891071X
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: