Provider Demographics
NPI:1376805812
Name:JACKSON, NATHAN ANDREW MERL (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW MERL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 RIVERSIDE DR STE D
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-5173
Mailing Address - Country:US
Mailing Address - Phone:434-792-0423
Mailing Address - Fax:
Practice Address - Street 1:117 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4101
Practice Address - Country:US
Practice Address - Phone:434-792-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014572207Q00000X
VA1376805821207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARES0000Medicare UPIN