Provider Demographics
NPI:1063951945
Name:JACKSON, EVANS
Entity type:Individual
Prefix:
First Name:EVANS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 10228
Mailing Address - Street 2:115-116A
Mailing Address - City:ST. THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00801
Mailing Address - Country:US
Mailing Address - Phone:340-227-7579
Mailing Address - Fax:
Practice Address - Street 1:39 SUB BASE
Practice Address - Street 2:
Practice Address - City:ST. THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00803
Practice Address - Country:US
Practice Address - Phone:340-227-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1869766174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator