Provider Demographics
NPI:1295029767
Name:JACKSON, MAGGIE (RDH (BSDH/MASTER OF)
Entity Type:Individual
Prefix:MS
First Name:MAGGIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDH (BSDH/MASTER OF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TOWNE SQUARE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607
Mailing Address - Country:US
Mailing Address - Phone:757-247-3174
Mailing Address - Fax:
Practice Address - Street 1:4000 COAST GUARD BLVD.
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-483-8596
Practice Address - Fax:757-483-8610
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402003432124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist