Individual
MISHI KAVON JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1471 JAG BRANCH BLVD UNIT 103, KERNERSVILLE, NC 27284-6963
(336) 515-7410
(336) 515-7419
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
200600012
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
141YE
BCBS OF NC
NC
01
—
187165
MEDCOST
NC
01
—
42515
PARTNERS MEDICARE
NC
05
—
5904650
—
NC
01
—
P00650299
RR MEDICARE
NC
Enumeration date
11/07/2006
Last updated
03/07/2023
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