Provider Demographics
NPI:1811409535
Name:JACKSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26048 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:RHOADESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22542-8549
Mailing Address - Country:US
Mailing Address - Phone:540-219-6889
Mailing Address - Fax:
Practice Address - Street 1:26048 PINE TREE RD
Practice Address - Street 2:
Practice Address - City:RHOADESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22542-8549
Practice Address - Country:US
Practice Address - Phone:540-219-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver