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General NPI Number Information
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NPI Number | 1063911105
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Entity Type | Individual
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Provider Name | JOHN MARTIN JACKSON
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Gender | Male
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Dates
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Enumeration Date | 02/05/2018
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Last Update Date | 02/05/2018
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Provider Practice Location Address
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Address Line | 11118 LANTERN WAY
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-3575
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Country | US
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Telephone | 646-408-0535
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7523
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City | RICHMOND
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State | VA
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Zip | 23231-0023
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306602301
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License Number State | VA
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