Provider Demographics
NPI:1992152672
Name:JACKSON, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
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 1:421 LIVELY HOPE RD
Mailing Address - Street 2:
Mailing Address - City:CALLAO
Mailing Address - State:VA
Mailing Address - Zip Code:22435-2511
Mailing Address - Country:US
Mailing Address - Phone:804-296-8250
Mailing Address - Fax:804-529-5005
Practice Address - Street 1:421 LIVELY HOPE RD
Practice Address - Street 2:
Practice Address - City:CALLAO
Practice Address - State:VA
Practice Address - Zip Code:22435-2511
Practice Address - Country:US
Practice Address - Phone:804-296-8250
Practice Address - Fax:804-529-5005
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)