Provider Demographics
NPI:1104812932
Name:JACKSON-MOORE, LISA ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:JACKSON-MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 OLD CLINIC BLDG
Mailing Address - Street 2:CB#7570
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-7570
Mailing Address - Country:US
Mailing Address - Phone:919-843-8750
Mailing Address - Fax:919-966-6001
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:919-843-7850
Practice Address - Fax:919-966-6001
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-00992207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891120RMedicaid
NC891120RMedicaid
2252993AMedicare ID - Type Unspecified