Healthcare Provider Details

I. General information

NPI: 1124013743
Provider Name (Legal Business Name): WILLIAM NEAL JACKSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N CAMERON ST STE 100
WINCHESTER VA
22601-6018
US

IV. Provider business mailing address

2086 MORGAN FREDERICK GRADE
CROSS JUNCTION VA
22625-1717
US

V. Phone/Fax

Practice location:
  • Phone: 540-536-1680
  • Fax: 540-662-5321
Mailing address:
  • Phone: 706-840-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18740
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN049375 NP
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024172458
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: