Healthcare Provider Details

I. General information

NPI: 1720552862
Provider Name (Legal Business Name): LINDSEY A JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 N DUKE ST FL 1
DURHAM NC
27704-2102
US

IV. Provider business mailing address

102 WAVERLY PL
DURHAM NC
27713-9733
US

V. Phone/Fax

Practice location:
  • Phone: 919-660-2200
  • Fax:
Mailing address:
  • Phone: 828-719-7028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5011356
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: