NPIMap

Individual provider Active NPI

Nicole Etta Jackson, DO

  • Family Medicine Physician
  • Dallas, TX
National Provider Identifier
1578084927
Registry record updated Sep 25, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
W7943 Issued in TX
Practice address
325 N Saint Paul St Ste 3100
Dallas, TX 75201-3923
Phone
(617) 505-1520
Fax
(617) 928-8401
NPI assigned
Jul 6, 2017
Last updated
Sep 25, 2026By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 25, 2026

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 2020-04019 NC
Family Medicine Physician 207Q00000X 009754 GA
Family Medicine Physician 207Q00000X W7943 TX Primary

Addresses

Primary practice location

325 N Saint Paul St Ste 3100
Dallas, TX 75201-3923

Mailing address

109 State St Ste 5
Boston, MA 02109-2906
Phone (617) 505-1520

Other names 1

  • Nicole Etta Bostic Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20201008000670 NC Practitioner - Family Practice 6800162603 Reassigns benefits to 7 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Legacy Healthcare Services IncGroup PAC ID 2163339722, shared by 46 NPIs, 3,431 clinicians
FHPG LLCGroup PAC ID 9537481569, 195 clinicians

Practice addresses (Care Compare)

101 Brucewood Rd
Southern Pines, NC 28387-5159
Phone (910) 970-4713

104 Physicians Park Dr
Rockingham, NC 28379-5204
Phone (910) 895-1989

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
85.84 of 100Reported as group
Quality
79.14
Promoting interoperability
92
Improvement activities
40
Cost
80.32

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
009754GAMDOccupational Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
MCPC-8, LLC Family Medicine CurrentSince Feb 14, 2025 Accepting new patients
Firsthealth of the Carolinas, Inc. Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
MCPC-2, LLC CurrentSince Oct 5, 2020 Accepting new patients
MCPC-17, LLC CurrentSince Oct 5, 2020 Accepting new patients
Firsthealth of the Carolinas, Inc Dba Firsthealth Weight Management Clinic CurrentSince Oct 5, 2020 Accepting new patients
FHPG, LLC Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
MCPC-8, LLC Family Medicine Current Accepting new patients
MCPC-8, LLC Family Medicine CurrentSince Feb 14, 2025 Accepting new patients
FHPG, LLC Family Medicine Current Accepting new patients
FHPG, LLC Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
MCPC-7, LLC Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
MCPC-17, LLC Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
MCPC-16, LLC Family Medicine CurrentSince Oct 5, 2020 Accepting new patients
FHPG, LLC Family Medicine Past Accepting new patients

Locations

225 Capital Dr
Ste 101
Carthage, NC 28327
Phone (910) 215-5100

112 E Ballard St
Ellerbe, NC 28338
Phone (910) 652-2663

104 Rice St
Hamlet, NC 28345
Phone (910) 582-4003

293 Olmsted Blvd
Ste 1
Pinehurst, NC 28374
Phone (910) 255-0033

155 Memorial Dr
Pinehurst, NC 28374
Phone (910) 215-1000

6322 Fayetteville Rd
Raeford, NC 28376
Phone (910) 878-6700

104 Physicians Park Dr
Rockingham, NC 28379
Phone (910) 895-1989

1690 US Highway 1 S
Ste 200
Southern Pines, NC 28387
Phone (910) 684-5159

1690 US Highway 1 S
Ste 100
Southern Pines, NC 28387
Phone (910) 684-2055

522 Allen St
Ste 101
Troy, NC 27371
Phone (910) 571-5510

7473 NC 22 Hwy
Whispering Pines, NC 28327
Phone (910) 215-5100

Organizations & group practices 15

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

View all 15

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1499299200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1790294400000",
    "number": "1578084927",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 STATE ST STE 5",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "021092906",
            "telephone_number": "617-505-1520",
            "fax_number": "617-928-8401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "325 N SAINT PAUL ST STE 3100",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752013923",
            "telephone_number": "617-505-1520",
            "fax_number": "617-928-8401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "NICOLE",
        "middle_name": "ETTA",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-07-06",
        "last_updated": "2026-09-25",
        "certification_date": "2026-09-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NC",
            "license": "2020-04019",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "009754",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "W7943",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "BOSTIC",
            "middle_name": "ETTA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Dallas, TX

Sources for this page

Verify at the official NPI Registry.