Provider Demographics
NPI:1558379362
Name:JACKSON, MICHAEL WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4931
Mailing Address - Country:US
Mailing Address - Phone:757-539-4034
Mailing Address - Fax:
Practice Address - Street 1:100 FAIRVIEW DR
Practice Address - Street 2:SOUTHAMPTON MEMORIAL HOSPITAL
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1238
Practice Address - Country:US
Practice Address - Phone:757-569-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24099232367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered