Provider Demographics
NPI:1427034982
Name:THE JACKSON CLINICS LLC
Entity Type:Organization
Organization Name:THE JACKSON CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:540-687-8181
Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-1769
Mailing Address - Country:US
Mailing Address - Phone:540-687-8181
Mailing Address - Fax:540-687-8256
Practice Address - Street 1:107 W FEDERAL ST
Practice Address - Street 2:BUILDING A, SUITE 1
Practice Address - City:MIDDLEBURG
Practice Address - State:VA
Practice Address - Zip Code:20117-2633
Practice Address - Country:US
Practice Address - Phone:540-687-8181
Practice Address - Fax:540-687-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09567Medicare PIN
DCG01886Medicare PIN