Provider Demographics
NPI:1124164173
Name:JACKSON, PHARNETHIA GOODMAN (NP-C)
Entity type:Individual
Prefix:
First Name:PHARNETHIA
Middle Name:GOODMAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 GODWIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8501
Mailing Address - Country:US
Mailing Address - Phone:757-983-8650
Mailing Address - Fax:
Practice Address - Street 1:2760 GODWIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8501
Practice Address - Country:US
Practice Address - Phone:757-983-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001120025163W00000X
VA0017137032363LF0000X
VA0024164290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10410Medicare PIN