Provider Demographics
NPI:1992134423
Name:G HAGAN JACKSON MD PC
Entity type:Organization
Organization Name:G HAGAN JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:HAGAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-588-6993
Mailing Address - Street 1:PO BOX 4319
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-4319
Mailing Address - Country:US
Mailing Address - Phone:804-588-6993
Mailing Address - Fax:
Practice Address - Street 1:5231 HICKORY PARK DR
Practice Address - Street 2:SUITE D
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-2619
Practice Address - Country:US
Practice Address - Phone:804-588-6993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012382192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty