Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1356990022 |
---|---|
Provider Name | Porshai Juanice Jackson |
First Address | Charlotte, NC 28213-5532 |
Second Address | Charlotte, NC 28213-5532 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/09/2019 |
Last Update Date | 05/09/2019 |