Provider Demographics
NPI:1427642636
Name:JACKSON, JUSTIN (NP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-5011
Mailing Address - Country:US
Mailing Address - Phone:276-228-8686
Mailing Address - Fax:276-228-4125
Practice Address - Street 1:1375 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-228-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily