Provider Demographics
NPI:1124013743
Name:JACKSON, WILLIAM NEAL (NP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:NEAL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2086 MORGAN FREDERICK GRADE
Mailing Address - Street 2:
Mailing Address - City:CROSS JUNCTION
Mailing Address - State:VA
Mailing Address - Zip Code:22625-1717
Mailing Address - Country:US
Mailing Address - Phone:706-840-2619
Mailing Address - Fax:
Practice Address - Street 1:301 N CAMERON ST STE 100
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6018
Practice Address - Country:US
Practice Address - Phone:540-536-1680
Practice Address - Fax:540-662-5321
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18740363LF0000X
GARN049375 NP363LF0000X
VA0024172458363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ48989Medicare UPIN