Healthcare Provider Details

I. General information

NPI: 1902669252
Provider Name (Legal Business Name): CLAYTON JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14431 SOMMERVILLE CT STE A
MIDLOTHIAN VA
23113-6812
US

IV. Provider business mailing address

14431 SOMMERVILLE CT STE A
MIDLOTHIAN VA
23113-6812
US

V. Phone/Fax

Practice location:
  • Phone: 804-265-4784
  • Fax:
Mailing address:
  • Phone: 804-265-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401419354
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: