Healthcare Provider Details

I. General information

NPI: 1548345325
Provider Name (Legal Business Name): EUGENE F JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EXECUTIVE DR SUITE A
DANVILLE VA
24541-4155
US

IV. Provider business mailing address

109 BRIDGE ST STE 300
DANVILLE VA
24541-1222
US

V. Phone/Fax

Practice location:
  • Phone: 434-793-4711
  • Fax: 434-797-2514
Mailing address:
  • Phone: 434-793-4711
  • Fax: 434-797-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110840446
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: