Healthcare Provider Details

I. General information

NPI: 1104283365
Provider Name (Legal Business Name): KAYLYN A JACKSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLYN PRICE PA

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CRYSTAL SPRING AVE SW STE 201
ROANOKE VA
24014-2465
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-853-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011711
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110-005201
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: