Provider Demographics
NPI:1669407003
Name:JACKSON, HORACE J (MD)
Entity type:Individual
Prefix:
First Name:HORACE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W LEIGH STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220
Mailing Address - Country:US
Mailing Address - Phone:804-788-0556
Mailing Address - Fax:804-788-1141
Practice Address - Street 1:505 W LEIGH STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-788-0556
Practice Address - Fax:804-788-1141
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035670207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006954OtherANTHEM BS
VA006049656Medicaid
VA110000329Medicare PIN
B09238Medicare UPIN