1245239227 NPI number — THERESA G JACKSON MD

Table of content: THERESA G JACKSON MD (NPI 1245239227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245239227 NPI number — THERESA G JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
THERESA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245239227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3640 HIGH ST
Provider Second Line Business Mailing Address:
SUITE 2A
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23707-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-397-6930
Provider Business Mailing Address Fax Number:
757-397-4864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3640 HIGH ST
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23707-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-397-6930
Provider Business Practice Location Address Fax Number:
757-397-4864
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101050002 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 0101050002 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005602785 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080007399 . This is a "MEDICARE INDIVIDUAL PROVIDER ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00799688 . This is a "RR MEICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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