MEDICARE: MRS. LUSAYO JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1093541047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LUSAYO JACKSON

Provider Business Mailing Address
First Line	:	2700 THACKERY RD APT 9
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-8686
Country	:	US
Telephone Number	:	202-480-5822
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 SANCAR WAY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-2874
Country	:	US
Telephone Number	:	252-557-8537
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	06/18/2026

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