Provider Demographics
NPI:1760481717
Name:JACKSON, WILLIAM G (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 HILLPOINT BLVD N
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-7181
Mailing Address - Country:US
Mailing Address - Phone:757-934-3434
Mailing Address - Fax:757-538-9038
Practice Address - Street 1:2050 HILLPOINT BLVD N
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-7181
Practice Address - Country:US
Practice Address - Phone:757-934-3434
Practice Address - Fax:757-538-9038
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005693811Medicaid
VA080001303Medicare ID - Type Unspecified
VA005693811Medicaid