Provider Demographics
NPI:1568493807
Name:EACKLES, JAY D (MED)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:D
Last Name:EACKLES
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 LOCKWOOD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4479
Mailing Address - Country:US
Mailing Address - Phone:757-874-4665
Mailing Address - Fax:757-874-1286
Practice Address - Street 1:808 TRITON CT STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4520
Practice Address - Country:US
Practice Address - Phone:757-874-4665
Practice Address - Fax:757-874-1286
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000257231H00000X
VA2101 000439237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0723576002OtherCIGNA PROVIDER#
VA148932100OtherDEPT OF LABOR PROVIDER#
VAP00179152OtherMEDICARE RAILROAD PROVIDE
VA112848OtherANTHEM PROVIDER#
VA540972387OtherAETNA/TRICARE PROVIDER#
VA51143OtherSENTARA/OPTIMA PROVIDER#