Provider Demographics
NPI:1124466438
Name:JACKSON, AMANDA M (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0004
Mailing Address - Country:US
Mailing Address - Phone:301-295-2045
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 JACKSON AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-968-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-08
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258417207V00000X
DCMD047097207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology