Healthcare Provider Details

I. General information

NPI: 1659572212
Provider Name (Legal Business Name): PAULETTE JACKSON CPED RESP THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MAIN STREET
LEWISTON NC
27849
US

IV. Provider business mailing address

PO BOX 98
LEWISTON NC
27849
US

V. Phone/Fax

Practice location:
  • Phone: 252-826-4040
  • Fax:
Mailing address:
  • Phone: 252-348-4000
  • Fax: 252-348-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number9579
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberA1145
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: