Provider Demographics
NPI:1316688906
Name:BEASTON, JACKIE LYNN (RN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:BEASTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNN
Other - Last Name:BROCKINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:150 PINE STATE ST
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-9414
Mailing Address - Country:US
Mailing Address - Phone:910-814-2425
Mailing Address - Fax:910-814-2429
Practice Address - Street 1:150 PINE STATE ST
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9414
Practice Address - Country:US
Practice Address - Phone:910-814-2425
Practice Address - Fax:910-814-2429
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC270786163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse