Healthcare Provider Details

I. General information

NPI: 1043141781
Provider Name (Legal Business Name): JENNIFER JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2092 TIGER EYE CT
WINSTON SALEM NC
27127-8009
US

IV. Provider business mailing address

PO BOX 246
KERNERSVILLE NC
27285-0246
US

V. Phone/Fax

Practice location:
  • Phone: 336-986-6688
  • Fax:
Mailing address:
  • Phone: 336-986-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: