MEDICARE: MR. HENRY EDWARD JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	226300000X	Kinesiotherapist

General Provider Information

NPI Number	:	1124441621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY EDWARD JACKSON

Provider Business Mailing Address
First Line	:	1703 GEORGIA AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220
Country	:	US
Telephone Number	:	804-873-6884
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 GEORGIA AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220
Country	:	US
Telephone Number	:	804-873-6884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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Directions to “ MR. HENRY EDWARD JACKSON ” Practice Location

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