Provider Demographics
NPI:1851634877
Name:JACKSON, VAN RIEVES IV (DPM)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:RIEVES
Last Name:JACKSON
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATE ST APT 1708
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3614
Mailing Address - Country:US
Mailing Address - Phone:214-336-5860
Mailing Address - Fax:
Practice Address - Street 1:360 STATE ST APT 1708
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3614
Practice Address - Country:US
Practice Address - Phone:214-336-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program