MEDICARE: CHIQUITA MICHONE THOMAS-JACKSON NP

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	363LA2200X	Adult Health Nurse Practitioner	0024178799	VA

General Provider Information

NPI Number	:	1184294415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIQUITA MICHONE THOMAS-JACKSON NP

Provider Business Mailing Address
First Line	:	307 S 17TH AVE
Second Line	:
City	:	HOPEWELL
State	:	VA
Zip	:	23860-3609
Country	:	US
Telephone Number	:	757-678-6682
Fax Number	:

Provider Business Practice Location Address
First Line	:	3916 S CRATER RD
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-9202
Country	:	US
Telephone Number	:	804-526-4300
Fax Number	:

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

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/30/2021

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