Healthcare Provider Details

I. General information

NPI: 1124441621
Provider Name (Legal Business Name): MR. HENRY EDWARD JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 GEORGIA AVE
RICHMOND VA
23220
US

IV. Provider business mailing address

1703 GEORGIA AVE
RICHMOND VA
23220
US

V. Phone/Fax

Practice location:
  • Phone: 804-873-6884
  • Fax:
Mailing address:
  • Phone: 804-873-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: