Healthcare Provider Details

I. General information

NPI: 1457646465
Provider Name (Legal Business Name): CHRISTINA MICHELLE JACKSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA MARY MICHELLE RICE

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEADE PKWY STE 150
SUFFOLK VA
23434-4259
US

IV. Provider business mailing address

PO BOX 7068
PORTSMOUTH VA
23707-0068
US

V. Phone/Fax

Practice location:
  • Phone: 757-934-9314
  • Fax: 757-539-7523
Mailing address:
  • Phone: 757-686-3508
  • Fax: 757-686-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0116023927
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0102203826
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: