Healthcare Provider Details

I. General information

NPI: 1013024603
Provider Name (Legal Business Name): MT. JACKSON FAMILY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5173 MAIN ST
MOUNT JACKSON VA
22842-9513
US

IV. Provider business mailing address

5173 NORTH MAIN STREET
MT. JACKSON VA
22664
US

V. Phone/Fax

Practice location:
  • Phone: 540-477-3808
  • Fax: 540-477-2719
Mailing address:
  • Phone: 540-477-3808
  • Fax: 540-477-2719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA A TAYLOR
Title or Position: DIRECTOR
Credential:
Phone: 540-459-1111