Basic Information
| Provider Information | |||||||||
| NPI: | 1366180101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | N.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 MACKENAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193712848 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11 MACKENAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193712848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2022 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-22-214490 | NC | Y |
No ID Information.