Provider Demographics
NPI:1982623625
Name:JACKSON, TIMOTHY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2206 EXECUTIVE DR STE F
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2583
Practice Address - Country:US
Practice Address - Phone:757-825-1440
Practice Address - Fax:757-825-1587
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q11340Medicare UPIN