Provider Demographics
NPI:1578112496
Name:JACKSON, JASMINE SHANAE (NP)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:SHANAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 S CRATER RD STE B
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9252
Mailing Address - Country:US
Mailing Address - Phone:804-733-6960
Mailing Address - Fax:
Practice Address - Street 1:3400 S CRATER RD STE B
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-733-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178156363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily