MEDICARE: THERESA G JACKSON MD

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	208100000X	Physical Medicine & Rehabilitation Physician	0101050002	VA
2	207Q00000X	Family Medicine Physician	0101050002	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	080007399	OTHER	VA	MEDICARE INDIVIDUAL PROVIDER ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00799688	OTHER	VA	RR MEICARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245239227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA G JACKSON MD

Provider Business Mailing Address
First Line	:	3640 HIGH ST
Second Line	:	SUITE 2A
City	:	PORTSMOUTH
State	:	VA
Zip	:	23707-3213
Country	:	US
Telephone Number	:	757-397-6930
Fax Number	:	757-397-4864

Provider Business Practice Location Address
First Line	:	3640 HIGH ST
Second Line	:	SUITE 2A
City	:	PORTSMOUTH
State	:	VA
Zip	:	23707-3213
Country	:	US
Telephone Number	:	757-397-6930
Fax Number	:	757-397-4864

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/24/2025

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Directions to “ THERESA G JACKSON MD” Practice Location

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