Provider Demographics
NPI:1962186486
Name:JACKSON, MARGARET DENISE
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:DENISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:208 HASTINGS LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3324
Mailing Address - Country:US
Mailing Address - Phone:252-698-9192
Mailing Address - Fax:
Practice Address - Street 1:208 HASTINGS LN
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3324
Practice Address - Country:US
Practice Address - Phone:252-698-9192
Practice Address - Fax:833-901-0451
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician