Healthcare Provider Details

I. General information

NPI: 1689169260
Provider Name (Legal Business Name): JESSICA RECHELLE JACKSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 W HUDSON BLVD
GASTONIA NC
28052-6430
US

IV. Provider business mailing address

991 W HUDSON BLVD
GASTONIA NC
28052-6430
US

V. Phone/Fax

Practice location:
  • Phone: 704-853-5191
  • Fax: 704-671-1404
Mailing address:
  • Phone: 704-853-5191
  • Fax: 704-671-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11511
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: