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General NPI Number Information
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NPI Number | 1962909259
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Entity Type | Individual
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Provider Name | JATAI JACKSON
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Gender | Female
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Dates
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Enumeration Date | 04/12/2018
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Last Update Date | 12/02/2024
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Provider Practice Location Address
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Address Line | 15022 SUNNY RIDGE CT
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3967
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Country | US
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Telephone | 202-439-3667
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Fax |
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Provider Business Mailing Address
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Address Line | 15022 SUNNY RIDGE CT APT 203
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3967
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Country | US
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Telephone | 202-439-3667
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 12201
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License Number State | VA
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