Healthcare Provider Details

I. General information

NPI: 1548989130
Provider Name (Legal Business Name): VANESSA YEPEZ JACKSON STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 WESTLAKE RD
FAYETTEVILLE NC
28314-4869
US

IV. Provider business mailing address

5668 JUNEBERRY LN
FAYETTEVILLE NC
28304-4859
US

V. Phone/Fax

Practice location:
  • Phone: 910-864-2944
  • Fax:
Mailing address:
  • Phone: 910-885-3431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14238
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: