MEDICARE: MISS TONYA TONIQUE JACKSON APRN

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	363LP2300X	Primary Care Nurse Practitioner	0024195649	VA
2	363LA2200X	Adult Health Nurse Practitioner	0024195649	VA

General Provider Information

NPI Number	:	1568326569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TONYA TONIQUE JACKSON APRN

Provider Business Mailing Address
First Line	:	563 SOUTHPARK BLVD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3610
Country	:	US
Telephone Number	:	804-431-5626
Fax Number	:

Provider Business Practice Location Address
First Line	:	563 SOUTHPARK BLVD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3610
Country	:	US
Telephone Number	:	804-431-5626
Fax Number	:

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

Provider Enumeration Date	:	12/13/2025
Last Update Date	:	12/15/2025

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