MEDICARE: AZEB 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	225100000X	Physical Therapist	2305203530	VA

General Provider Information

NPI Number	:	1588498075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZEB JACKSON

Provider Business Mailing Address
First Line	:	5000 DOGWOOD TRL
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-3806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 HIGH ST W
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4226
Country	:	US
Telephone Number	:	757-354-6988
Fax Number	:

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

Provider Enumeration Date	:	08/28/2024
Last Update Date	:	08/28/2024

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Directions to “ AZEB JACKSON ” Practice Location

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