Jalisa Jackson

Primary specialty

Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X

License

MHL-036-348 Issued in NC

Practice address

11413 Mangla Dr
Charlotte, NC 28214-8885

Phone

(704) 819-4909

NPI assigned

Oct 19, 2020

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Urbanized LLC

  • Mental Illness Community Based Residential Treatment Facility
  • Charlotte, NC
  • NPI 1346840261

  Community Based Residential Treatment Facility, Mental Illness

  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1603065600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603065600000",
    "number": "1366041667",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11413 MANGLA DR",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282148885",
            "telephone_number": "704-819-4909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11413 MANGLA DR",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282148885",
            "telephone_number": "704-819-4909"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "JALISA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-10-19",
        "last_updated": "2020-10-19",
        "certification_date": "2020-10-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "NC",
            "license": "MHL-036-348",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Emanuel Mason Jackson, MD
• Erica Jackson, OT
• Henretta Collin Jackson, DMIN
• Jacqueline Landa Jackson, M.ED., BCBA
• Jacquelyn Chrisana Jackson, MD
• Jasmine Dearis Jackson, PHARMD
• Jennifer Davis Jackson, LCAS
• Jessica Lynn Jackson, FNP
• John Mark Jackson, LPC
• Julia Dawn Jackson, MED, ATC, LAT

• Mental Illness Community Based Residential Treatment Facility in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Mental Illness Community Based Residential Treatment Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.