Healthcare Provider Details

I. General information

NPI: 1104590140
Provider Name (Legal Business Name): JACKSON CROUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 SALEM RD
VIRGINIA BEACH VA
23456-1393
US

IV. Provider business mailing address

3676 MALIBU PALMS DR APT 203
VIRGINIA BEACH VA
23452-3676
US

V. Phone/Fax

Practice location:
  • Phone: 757-471-1053
  • Fax:
Mailing address:
  • Phone: 717-468-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202219776
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: