Provider Demographics
NPI:1083904502
Name:JACKSON, WILLIAM MATERSON (CRNFA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MATERSON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 BRUNSWICK DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-1988
Mailing Address - Country:US
Mailing Address - Phone:540-953-1970
Mailing Address - Fax:
Practice Address - Street 1:1730 BRUNSWICK DR
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-1988
Practice Address - Country:US
Practice Address - Phone:540-953-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001170063163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant