Provider Demographics
NPI:1790891687
Name:MORGAN, JACKIE L (PA C)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:MORGAN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-0969
Mailing Address - Country:US
Mailing Address - Phone:540-674-8900
Mailing Address - Fax:540-674-9121
Practice Address - Street 1:5562 COUGAR TRAIL RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-0969
Practice Address - Country:US
Practice Address - Phone:540-674-8900
Practice Address - Fax:540-674-9121
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110840575OtherPHYSICIAN ASST LICENSE #