Healthcare Provider Details

I. General information

NPI: 1578201612
Provider Name (Legal Business Name): JACKSON SEIPP PERRY MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4226
US

IV. Provider business mailing address

1400 MASON FARM RD UNIT A
CHAPEL HILL NC
27514-4606
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-1000
  • Fax:
Mailing address:
  • Phone: 252-560-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRTL22-0415
License Number StateNC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: