Provider Demographics
NPI:1578644290
Name:JACKSON, RICHARD ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E LEIGH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1410
Mailing Address - Country:US
Mailing Address - Phone:804-225-7148
Mailing Address - Fax:804-225-7159
Practice Address - Street 1:304 E LEIGH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1410
Practice Address - Country:US
Practice Address - Phone:804-225-7148
Practice Address - Fax:804-225-7159
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0542922OtherANTHEM/TRIGON/HMO/PPO/HEA
VA541588928OtherUNITEDHEALTHCARE
VA541588928OtherVA COORDINATED CARE
VA44130OtherSENTAR
VA541588928OtherSOUTHERHEALTH
VA541588928OtherVA PREMIER
VA541588928OtherPHCS
VA006044140Medicaid
VA541588928OtherVIRGINIA HEALTH NETWORK
VAC03251OtherMCR GROUP#
VA491268OtherAETNA/HMO/PPO
VA041765-00000OtherQUAL CHOICE
VA110054158OtherMCR RAILROAD
VA541588928/4971410007OtherCIGNA/HMO/PPO
VA541588928/4971410007OtherCIGNA/HMO/PPO
VA0542922OtherANTHEM/TRIGON/HMO/PPO/HEA