Provider Demographics
NPI:1497145189
Name:JACKSON, SHAYLIE
Entity Type:Individual
Prefix:
First Name:SHAYLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 FIRST COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6119
Mailing Address - Country:US
Mailing Address - Phone:757-428-2666
Mailing Address - Fax:757-451-7307
Practice Address - Street 1:525 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6119
Practice Address - Country:US
Practice Address - Phone:757-428-2666
Practice Address - Fax:757-451-7307
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230023817247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other