Provider Demographics
NPI:1689629099
Name:JACKSON, AUTUMN A (MHS, PA-C)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:A
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHS, PA-C
Mailing Address - Street 1:7832 TILGHMAN ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2579
Mailing Address - Country:US
Mailing Address - Phone:202-276-8671
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:INOVA FAIRFAX ED
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003077363AM0700X
VA0110002073363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical