Provider Demographics
NPI:1417443987
Name:JACKSON, ADRIENNE (AUD)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:GREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-388-6200
Mailing Address - Fax:757-388-6201
Practice Address - Street 1:600 GRESHAM DR STE 1100
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507
Practice Address - Country:US
Practice Address - Phone:757-388-6200
Practice Address - Fax:757-388-6201
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001697231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist