Provider Demographics
NPI:1508240854
Name:JACKSON, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
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:PO BOX 2016
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2016
Mailing Address - Country:US
Mailing Address - Phone:276-880-2330
Mailing Address - Fax:276-880-2329
Practice Address - Street 1:97 KNOBS LANE
Practice Address - Street 2:
Practice Address - City:CEDAR BLUFF
Practice Address - State:VA
Practice Address - Zip Code:24609-3205
Practice Address - Country:US
Practice Address - Phone:276-880-2330
Practice Address - Fax:276-880-2329
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA104344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi