Healthcare Provider Details

I. General information

NPI: 1073587598
Provider Name (Legal Business Name): WOODY H JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 3515
CHAPEL HILL NC
27515-3515
US

V. Phone/Fax

Practice location:
  • Phone: 910-815-5830
  • Fax: 910-815-5698
Mailing address:
  • Phone: 919-308-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD063122L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD063122L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: