Healthcare Provider Details

I. General information

NPI: 1124466438
Provider Name (Legal Business Name): AMANDA M JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2013
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

8901 WISCONSIN AVE
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2237
  • Fax:
Mailing address:
  • Phone: 301-295-2045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101258417
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD047097
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: