Provider Demographics
NPI:1528179215
Name:JACKSON, ANDREA M (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4376 GERMANNA HWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-2008
Practice Address - Country:US
Practice Address - Phone:540-972-7798
Practice Address - Fax:540-972-3536
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0025384207V00000X
NJ25MA11775800207V00000X
GA95446207V00000X
FLME161053207V00000X
VA0101039547207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528179215Medicaid
VAVAA100669Medicare PIN