Provider Demographics
NPI:1205433885
Name:LABOUE, JACKSON (PA-C)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:LABOUE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:5899 BREMO RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1935
Practice Address - Country:US
Practice Address - Phone:804-288-8512
Practice Address - Fax:804-288-4552
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2021-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110007683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant