Healthcare Provider Details

I. General information

NPI: 1285521575
Provider Name (Legal Business Name): GIA ANNALISE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MILLER ST
WINSTON SALEM NC
27103-2508
US

IV. Provider business mailing address

MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-8092
  • Fax: 336-716-8018
Mailing address:
  • Phone: 478-365-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: