Provider Demographics
NPI:1497629299
Name:JACKSON, VERNETTA
Entity type:Individual
Prefix:
First Name:VERNETTA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 SILVER MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-4544
Mailing Address - Country:US
Mailing Address - Phone:910-827-1126
Mailing Address - Fax:
Practice Address - Street 1:25 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-9105
Practice Address - Country:US
Practice Address - Phone:910-827-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF10250028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty