Provider Demographics
NPI:1811770753
Name:JACKSON, ERIN TANNER
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:TANNER
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 1:2503 ARLINGTON BLVD APT 101B
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-1318
Mailing Address - Country:US
Mailing Address - Phone:540-598-0275
Mailing Address - Fax:
Practice Address - Street 1:8008 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3109
Practice Address - Country:US
Practice Address - Phone:240-268-4687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0139000251170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS