Healthcare Provider Details

I. General information

NPI: 1063403020
Provider Name (Legal Business Name): JOHN M JACOCKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 04/27/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FBCH - AVIATION MEDICINE CLINIC 9300 DEWITT LOOP
FORT BELVOIR VA
22060
US

IV. Provider business mailing address

9815 S PARK CIR
FAIRFAX STATION VA
22039-2908
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-7334
  • Fax:
Mailing address:
  • Phone: 703-440-1088
  • Fax: 703-806-3591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7019
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number7019
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: