Healthcare Provider Details

I. General information

NPI: 1750186839
Provider Name (Legal Business Name): MILES ANDREW JACKSON HAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 W BROAD ST
RICHMOND VA
23294-5330
US

IV. Provider business mailing address

9440 W BROAD ST
RICHMOND VA
23294-5330
US

V. Phone/Fax

Practice location:
  • Phone: 804-253-0762
  • Fax:
Mailing address:
  • Phone: 804-253-0762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2101002858
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: