Healthcare Provider Details

I. General information

NPI: 1639675044
Provider Name (Legal Business Name): BENJAMIN JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 GREEN VALLEY RD
GREENSBORO NC
27408-7019
US

IV. Provider business mailing address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

V. Phone/Fax

Practice location:
  • Phone: 336-890-2530
  • Fax:
Mailing address:
  • Phone: 910-272-1478
  • Fax: 910-738-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2021-01092
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: