MEDICARE: CORNETTA KAY ORTONJACKSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0001120432	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235893744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORNETTA KAY ORTONJACKSON RN

Provider Business Mailing Address
First Line	:	4516 HUNTERS POINT DR
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-2220
Country	:	US
Telephone Number	:	757-724-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	4516 HUNTERS POINT DR
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-2220
Country	:	US
Telephone Number	:	757-724-2122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2021
Last Update Date	:	10/30/2021

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