Provider Demographics
NPI:1770941932
Name:JACKSON, THOMAS ADDISON (RPRS QMHP-A)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ADDISON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPRS QMHP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 W FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-1303
Mailing Address - Country:US
Mailing Address - Phone:434-249-0851
Mailing Address - Fax:434-218-0530
Practice Address - Street 1:652 W FREDERICK ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-3103
Practice Address - Country:US
Practice Address - Phone:434-249-0851
Practice Address - Fax:434-218-0530
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator