Healthcare Provider Details

I. General information

NPI: 1831409374
Provider Name (Legal Business Name): ANNIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 NORTHAVEN DR
CHARLOTTE NC
28206-1730
US

IV. Provider business mailing address

4616 NORTHAVEN DR
CHARLOTTE NC
28206-1730
US

V. Phone/Fax

Practice location:
  • Phone: 704-597-8370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number412
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: