Healthcare Provider Details

I. General information

NPI: 1073341418
Provider Name (Legal Business Name): KENDRA D JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 LITCHFORD FOREST LN APT 308
RALEIGH NC
27615-7173
US

IV. Provider business mailing address

PO BOX 28544
RALEIGH NC
27611-8544
US

V. Phone/Fax

Practice location:
  • Phone: 252-316-2170
  • Fax:
Mailing address:
  • Phone: 252-316-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: