Provider Demographics
NPI:1568825727
Name:JACKSON, VIRGIL ALOTHIN
Entity Type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:ALOTHIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-1865
Mailing Address - Country:US
Mailing Address - Phone:772-359-3127
Mailing Address - Fax:
Practice Address - Street 1:4003 AVENUE M
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-1865
Practice Address - Country:US
Practice Address - Phone:772-359-3127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251EOOOOOX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health