Individual
JALISA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
11413 MANGLA DR, CHARLOTTE, NC 28214-8885
(704) 819-4909
Mailing address
11413 MANGLA DR, CHARLOTTE, NC 28214-8885
(704) 819-4909
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
MHL-036-348
NC
Other
Enumeration date
10/19/2020
Last updated
10/19/2020
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