Basic Information
Provider Information
NPI: 1003149048
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: CHARLES
MiddleName: BARTLETT
NamePrefix:  
NameSuffix: JR.
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 355 S MADISON BLVD STE C1
Address2:  
City: ROXBORO
State: NC
PostalCode: 275735485
CountryCode: US
TelephoneNumber: 3365998366
FaxNumber: 3363226168
Practice Location
Address1: 355 S MADISON BLVD STE C1
Address2:  
City: ROXBORO
State: NC
PostalCode: 275735485
CountryCode: US
TelephoneNumber: 3365998366
FaxNumber: 3363226168
Other Information
ProviderEnumerationDate: 09/09/2009
LastUpdateDate: 09/06/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X1513NCN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
1041C0700XC007168NCY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
611213905NC MEDICAID


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