Healthcare Provider Details

I. General information

NPI: 1306440565
Provider Name (Legal Business Name): VALERIE DENISE JACKSON PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 SEVEN CORNERS CTR
FALLS CHURCH VA
22044-2409
US

IV. Provider business mailing address

903 MAHER CT
FORT WASHINGTON MD
20744-5937
US

V. Phone/Fax

Practice location:
  • Phone: 703-534-6688
  • Fax: 703-534-6683
Mailing address:
  • Phone: 301-292-9891
  • Fax: 301-292-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number0202006313
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: