Individual
MRS. GERTIE LOU JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
315 TRAM RD, MOUNT OLIVE, NC 28365-6436
(252) 550-1150
Mailing address
315 TRAM RD, MOUNT OLIVE, NC 28365-6436
(252) 550-1150
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05
—
NC
Enumeration date
05/09/2019
Last updated
05/09/2019
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