Provider Demographics
NPI:1235893744
Name:ORTONJACKSON, CORNETTA KAY (RN)
Entity Type:Individual
Prefix:
First Name:CORNETTA
Middle Name:KAY
Last Name:ORTONJACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 HUNTERS POINT DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2220
Mailing Address - Country:US
Mailing Address - Phone:757-724-2122
Mailing Address - Fax:
Practice Address - Street 1:4516 HUNTERS POINT DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2220
Practice Address - Country:US
Practice Address - Phone:757-724-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001120432163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA08111966Medicaid