Provider Demographics
NPI:1124441621
Name:JACKSON, HENRY EDWARD
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:EDWARD
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 1:1703 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220
Mailing Address - Country:US
Mailing Address - Phone:804-873-6884
Mailing Address - Fax:
Practice Address - Street 1:1703 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-873-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist