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NPI Code Detail

MEDICARE: AUTUMN A JACKSON MHS, PA-C

MEDICARE: AUTUMN A JACKSON MHS, PA-C
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
1363AM0700XMedical Physician AssistantC0003077MD
2363AM0700XMedical Physician Assistant0110002073VA

General Provider Information

NPI Number : 1689629099
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUTUMN A JACKSON MHS, PA-C
Provider Business Mailing Address
First Line : 7832 TILGHMAN ST
Second Line :
City : FULTON
State : MD
Zip : 20759-2579
Country : US
Telephone Number : 202-276-8671
Fax Number :
Provider Business Practice Location Address
First Line : 3300 GALLOWS RD
Second Line : INOVA FAIRFAX ED
City : FALLS CHURCH
State : VA
Zip : 22042-3307
Country : US
Telephone Number : 703-776-2690
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2006
Last Update Date : 07/11/2011

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Directions to “ AUTUMN A JACKSON MHS, PA-C” Practice Location

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