Healthcare Provider Details

I. General information

NPI: 1093541047
Provider Name (Legal Business Name): MRS. LUSAYO JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 SANCAR WAY
DURHAM NC
27713-2874
US

IV. Provider business mailing address

2700 THACKERY RD APT 9
GREENVILLE NC
27858-8686
US

V. Phone/Fax

Practice location:
  • Phone: 252-557-8537
  • Fax:
Mailing address:
  • Phone: 202-480-5822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: