Healthcare Provider Details

I. General information

NPI: 1790301281
Provider Name (Legal Business Name): DESYRE KIMBERLY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 POCAHONTAS PL
HAMPTON VA
23661-2434
US

IV. Provider business mailing address

734 POCAHONTAS PL
HAMPTON VA
23661-2434
US

V. Phone/Fax

Practice location:
  • Phone: 757-975-3813
  • Fax:
Mailing address:
  • Phone: 757-975-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: