Healthcare Provider Details

I. General information

NPI: 1063582864
Provider Name (Legal Business Name): CAROL BOWSER JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 FARRELL RD BLDG 815,RM 139
FORT BELVOIR VA
22060-5901
US

IV. Provider business mailing address

5805 TERENCE DR
CLINTON MD
20735-3742
US

V. Phone/Fax

Practice location:
  • Phone: 703-805-0498
  • Fax:
Mailing address:
  • Phone: 301-856-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberR103314
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: