Provider Demographics
NPI:1902603913
Name:JACKSON, TIMOTHY RANDALL JR
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RANDALL
Last Name:JACKSON
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEMBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28385-9784
Mailing Address - Country:US
Mailing Address - Phone:910-336-0152
Mailing Address - Fax:
Practice Address - Street 1:340A NORTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2424
Practice Address - Country:US
Practice Address - Phone:910-261-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician