Provider Demographics
NPI:1255537999
Name:JACKSON, JOHNNA MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:THS PHYSICIAN PARTNERS, INC-ADMIN OFFICE
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:500 POPLAR ST
Practice Address - Street 2:SUITE 304
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1474
Practice Address - Country:US
Practice Address - Phone:304-767-7770
Practice Address - Fax:304-767-7779
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1998208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810012767Medicaid
WV3810024049OtherGROUP MEDICAID
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID