Provider Demographics
NPI:1457684284
Name:JACKSON, HAZEL (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HAZEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7502 JUSTICE DR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-6101
Mailing Address - Country:US
Mailing Address - Phone:804-693-1090
Mailing Address - Fax:804-693-1093
Practice Address - Street 1:7502 JUSTICE DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-6101
Practice Address - Country:US
Practice Address - Phone:804-693-1090
Practice Address - Fax:804-693-1093
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002755363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical