Healthcare Provider Details

I. General information

NPI: 1477684280
Provider Name (Legal Business Name): MARSHA E JACKSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KING ST
ALEXANDRIA VA
22314-2716
US

IV. Provider business mailing address

12400 MARTIN RD
BRANDYWINE MD
20613-8745
US

V. Phone/Fax

Practice location:
  • Phone: 703-549-5070
  • Fax: 703-549-4821
Mailing address:
  • Phone: 301-372-6214
  • Fax: 301-372-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024105852
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR082221
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN33128
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: