Provider Demographics
NPI:1043925258
Name:JACKSON, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N BALLANCE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 TREETOP DR # 301
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-0606
Practice Address - Country:US
Practice Address - Phone:951-870-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13569224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification