Provider Demographics
NPI:1558843284
Name:JACKSON, DERCILLA
Entity Type:Individual
Prefix:
First Name:DERCILLA
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 1:163 AUBREYS LN
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:VA
Mailing Address - Zip Code:24521-3394
Mailing Address - Country:US
Mailing Address - Phone:434-826-9138
Mailing Address - Fax:
Practice Address - Street 1:163 AUBREYS LN
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:VA
Practice Address - Zip Code:24521-3394
Practice Address - Country:US
Practice Address - Phone:434-826-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60456749172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty