MEDICARE: ERIN SHUNKESHA JACKSON PHD

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	103T00000X	Psychologist	4147	NC

General Provider Information

NPI Number	:	1407929151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN SHUNKESHA JACKSON PHD

Provider Business Mailing Address
First Line	:	4030 WAKE FOREST RD STE 349
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-0010
Country	:	US
Telephone Number	:	407-579-1771
Fax Number	:

Provider Business Practice Location Address
First Line	:	11330 VANSTORY DR STE 109F
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-8146
Country	:	US
Telephone Number	:	980-705-4122
Fax Number	:

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

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	11/19/2024

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