Provider Demographics
NPI:1891756425
Name:JACKSON, PAMELA SUE (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 RIVERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2030
Mailing Address - Country:US
Mailing Address - Phone:434-200-4504
Mailing Address - Fax:434-200-4590
Practice Address - Street 1:3300 RIVERMONT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2030
Practice Address - Country:US
Practice Address - Phone:434-200-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175936363LN0000X, 363LN0000X
TXAP120193363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41189200Medicaid
TX752616977042OtherTRICARE
TX283629801Medicaid
TX283629801Medicaid
TX443339YMAFMedicare Oscar/Certification
TXTXB134272Medicare Oscar/Certification