Provider Demographics
NPI:1104590140
Name:CROUSE, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:CROUSE
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 1:3676 MALIBU PALMS DR APT 203
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3676
Mailing Address - Country:US
Mailing Address - Phone:717-468-0501
Mailing Address - Fax:
Practice Address - Street 1:1808 SALEM RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1393
Practice Address - Country:US
Practice Address - Phone:757-471-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist