Provider Demographics
NPI:1194450163
Name:JACKSON, ASHLEY NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 15TH ST NW STE 111
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1625
Mailing Address - Country:US
Mailing Address - Phone:276-679-7457
Mailing Address - Fax:
Practice Address - Street 1:96 15TH ST NW STE 111
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1625
Practice Address - Country:US
Practice Address - Phone:276-679-7457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116037321390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program