1255537999 NPI number — JOHNNA MICHELLE JACKSON D.O.

Table of content: JOHNNA MICHELLE JACKSON D.O. (NPI 1255537999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255537999 NPI number — JOHNNA MICHELLE JACKSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JOHNNA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1255537999
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 MACCORKLE AVE SW
Provider Second Line Business Mailing Address:
THS PHYSICIAN PARTNERS, INC-ADMIN OFFICE
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25309-1311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-414-4800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 POPLAR ST
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25309-1474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-767-7770
Provider Business Practice Location Address Fax Number:
304-767-7779
Provider Enumeration Date:
06/21/2007

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: 208600000X , with the licence number:  1998 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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