Basic Information
| Provider Information | |||||||||
| NPI: | 1366804163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JONATHON | ||||||||
| MiddleName: | TROY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 YORKSHIRE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288037785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282741600 | ||||||||
| FaxNumber: | 8282741603 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 YORKSHIRE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288037785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282741600 | ||||||||
| FaxNumber: | 8282741603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2017-02028 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1366804163 | 05 | NC | MEDICAID |