Healthcare Provider Details

I. General information

NPI: 1083904502
Provider Name (Legal Business Name): WILLIAM MATERSON JACKSON CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 BRUNSWICK DR
BLACKSBURG VA
24060-1988
US

IV. Provider business mailing address

1730 BRUNSWICK DR
BLACKSBURG VA
24060-1988
US

V. Phone/Fax

Practice location:
  • Phone: 540-953-1970
  • Fax:
Mailing address:
  • Phone: 540-953-1970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number0001170063
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: