Healthcare Provider Details

I. General information

NPI: 1609712496
Provider Name (Legal Business Name): MARTINA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 TAYLOR RD STE 201
CHESAPEAKE VA
23321-2246
US

IV. Provider business mailing address

2613 TAYLOR RD STE 201
CHESAPEAKE VA
23321-2246
US

V. Phone/Fax

Practice location:
  • Phone: 757-738-1600
  • Fax:
Mailing address:
  • Phone: 757-738-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024196709
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: