Provider Demographics
NPI:1477684280
Name:JACKSON, MARSHA E (CNM)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-8745
Mailing Address - Country:US
Mailing Address - Phone:301-372-6214
Mailing Address - Fax:301-372-1585
Practice Address - Street 1:1501 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2716
Practice Address - Country:US
Practice Address - Phone:703-549-5070
Practice Address - Fax:703-549-4821
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024105852367A00000X
MDR082221367A00000X
DCRN33128367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01647B02Medicare ID - Type UnspecifiedINDIVIDUAL