=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770941932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS ADDISON JACKSON RPRS QMHP-A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2016
-----------------------------------------------------
Last Update Date | 03/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 652 W FREDERICK ST
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24401-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-249-0851
-----------------------------------------------------
Fax | 434-218-0530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 652 W FREDERICK ST
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24401-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-249-0851
-----------------------------------------------------
Fax | 434-218-0530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------