Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 64988 | SC |
Y | 363L00000X | Nurse Practitioner | 930214 | NC |
NPI | 1013157437 |
---|---|
Provider Name | Pamela Jackson |
First Address | Charlotte, NC 28219-9305 |
Second Address | Charlotte, NC 28203-5866 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/02/2009 |
Last Update Date | 05/01/2022 |