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General NPI Number Information
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NPI Number | 1902669252
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Entity Type | Individual
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Provider Name | CLAYTON JACKSON
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Gender | Male
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Dates
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Enumeration Date | 01/31/2024
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Last Update Date | 01/05/2026
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Provider Practice Location Address
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Address Line | 14431 SOMMERVILLE CT STE A
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City | MIDLOTHIAN
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State | VA
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Zip | 23113-6812
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Country | US
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Telephone | 804-265-4784
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Fax |
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Provider Business Mailing Address
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Address Line | 14431 SOMMERVILLE CT STE A
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City | MIDLOTHIAN
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State | VA
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Zip | 23113-6812
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Country | US
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Telephone | 804-265-4784
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401419354
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License Number State | VA
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