=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417666595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSANNE P. JACKSON, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2022
-----------------------------------------------------
Last Update Date | 11/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 VILCOM CENTER DR STE 180
-----------------------------------------------------
City | CHAPEL HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27514-1789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-968-9874
-----------------------------------------------------
Fax | 919-869-1335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 VILCOM CENTER DR STE 180
-----------------------------------------------------
City | CHAPEL HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27514-1789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-968-9874
-----------------------------------------------------
Fax | 919-869-1335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. LISA G EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-968-9874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------