Healthcare Provider Details

I. General information

NPI: 1376805812
Provider Name (Legal Business Name): NATHAN ANDREW MERL JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 EXECUTIVE DR
DANVILLE VA
24541-4101
US

IV. Provider business mailing address

4545 RIVERSIDE DR STE D
DANVILLE VA
24541-5173
US

V. Phone/Fax

Practice location:
  • Phone: 434-792-0423
  • Fax:
Mailing address:
  • Phone: 434-792-0423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1376805821
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT014572
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: