MEDICARE: SHAYLIE 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	247200000X	Other Technician	0230023817	VA

General Provider Information

NPI Number	:	1497145189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAYLIE JACKSON

Provider Business Mailing Address
First Line	:	525 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6119
Country	:	US
Telephone Number	:	757-428-2666
Fax Number	:	757-451-7307

Provider Business Practice Location Address
First Line	:	525 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6119
Country	:	US
Telephone Number	:	757-428-2666
Fax Number	:	757-451-7307

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

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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