Provider Demographics
NPI:1295489276
Name:JACKSON, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-5232
Mailing Address - Country:US
Mailing Address - Phone:540-220-5261
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-5232
Practice Address - Country:US
Practice Address - Phone:540-220-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider