Provider Demographics
NPI:1992428890
Name:JACKSON, KATRINA E (LSA, CSFA)
Entity type:Individual
Prefix:MISS
First Name:KATRINA
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSA, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WOOD DUCK PL APT 303
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-8202
Mailing Address - Country:US
Mailing Address - Phone:757-300-3428
Mailing Address - Fax:
Practice Address - Street 1:500 MARTHA JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-654-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000370208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty