Basic Information
| Provider Information | |||||||||
| NPI: | 1215006192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MISHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 291 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369938181 | ||||||||
| FaxNumber: | 3369969539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200600012 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 42515 | 01 | NC | PARTNERS MEDICARE | OTHER | 187165 | 01 | NC | MEDCOST | OTHER | P00650299 | 01 | NC | RR MEDICARE | OTHER | 141YE | 01 | NC | BCBS OF NC | OTHER | 5904650 | 05 | NC | MEDICAID |