Provider Demographics
NPI:1588479703
Name:JACKSON, JASLYN ALIA
Entity type:Individual
Prefix:
First Name:JASLYN
Middle Name:ALIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 GREEN GARDEN CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-2846
Mailing Address - Country:US
Mailing Address - Phone:757-839-7900
Mailing Address - Fax:
Practice Address - Street 1:3448 GREEN GARDEN CIR APT 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-2846
Practice Address - Country:US
Practice Address - Phone:757-839-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist