Provider Demographics
NPI:1154392306
Name:JACKSON-MALINA, JUDITH (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:
Last Name:JACKSON-MALINA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 13TH AVENUE PL NW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2596
Mailing Address - Country:US
Mailing Address - Phone:828-322-8484
Mailing Address - Fax:828-324-9526
Practice Address - Street 1:221 13TH AVENUE PL NW
Practice Address - Street 2:SUITE 202
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2596
Practice Address - Country:US
Practice Address - Phone:828-322-8484
Practice Address - Fax:828-324-9526
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003530Medicaid
NC7003530Medicaid
NCQ26754Medicare UPIN