Provider Demographics
NPI:1124369863
Name:JACKSON, GEORGE HAGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HAGAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4319
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-4319
Mailing Address - Country:US
Mailing Address - Phone:804-588-6993
Mailing Address - Fax:
Practice Address - Street 1:5231 HICKORY PARK DR
Practice Address - Street 2:SUITE D
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-2619
Practice Address - Country:US
Practice Address - Phone:804-588-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012382192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF85311Medicare UPIN