Active NPI
Jerry Edwin Jackson Jr., LPC
- Professional Counselor
- Wilmington, NC
National Provider Identifier
1356423594
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 5109
- Practice address
- 3963 Market Street
Suite a
Wilmington, NC 28403 - Phone
- (910) 362-9474
- Fax
- (910) 362-9192
- NPI assigned
- Oct 19, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 5109 | NC | Primary |
Addresses
Primary practice location
3963 Market Street
Suite a
Wilmington, NC 28403
Mailing address
3963 Market Street
Suite a
Wilmington, NC 28403
Phone (910) 362-9474
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 6103285 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5109 | NC | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161216000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1356423594",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3963 MARKET STREET",
"address_2": "SUITE A",
"city": "WILMINGTON",
"state": "NC",
"postal_code": "28403",
"telephone_number": "910-362-9474",
"fax_number": "910-362-9192"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3963 MARKET STREET",
"address_2": "SUITE A",
"city": "WILMINGTON",
"state": "NC",
"postal_code": "28403",
"telephone_number": "910-362-9474",
"fax_number": "910-362-9192"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JERRY",
"middle_name": "EDWIN",
"name_suffix": "Jr.",
"credential": "LPC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-19",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "NC",
"license": "5109",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6103285",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Wilmington, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.