Basic Information
| Provider Information | |||||||||
| NPI: | 1003149048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | BARTLETT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C007168 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 1513 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6112139 | 05 | NC | MEDICAID |