Provider Demographics
NPI:1568697415
Name:ZACKRISSON, JILL ANNEMARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ANNEMARIE
Last Name:ZACKRISSON
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 1:2004 BREMO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2442
Mailing Address - Country:US
Mailing Address - Phone:804-442-7794
Mailing Address - Fax:804-767-2030
Practice Address - Street 1:2004 BREMO RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2442
Practice Address - Country:US
Practice Address - Phone:804-442-7794
Practice Address - Fax:804-767-2030
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00268207Q00000X
VA0101254457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VAC09633OtherGROUP PTAN